Provider Demographics
NPI:1073076105
Name:GADDIS, NICHOLE MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:MARIE
Last Name:GADDIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:MARIE
Other - Last Name:GALULLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1S376 SUMMIT AVE STE 4C
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3966
Mailing Address - Country:US
Mailing Address - Phone:630-424-1122
Mailing Address - Fax:
Practice Address - Street 1:109 FAIRFIELD WAY # 205
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108
Practice Address - Country:US
Practice Address - Phone:630-237-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0182931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical