Provider Demographics
NPI:1073184545
Name:BARAK, NICOLE M (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BARAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7547 BRISTOL LN UNIT 3
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-7231
Mailing Address - Country:US
Mailing Address - Phone:847-271-2825
Mailing Address - Fax:
Practice Address - Street 1:545 BELMONT LN
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2467
Practice Address - Country:US
Practice Address - Phone:630-523-8972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009245225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant