Provider Demographics
NPI:1073109005
Name:DIAZ, NICOLE MICHELLE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-2337
Mailing Address - Country:US
Mailing Address - Phone:630-396-0753
Mailing Address - Fax:
Practice Address - Street 1:1142 W MADISON ST STE 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2191
Practice Address - Country:US
Practice Address - Phone:312-324-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health