Provider Demographics
NPI:1114070828
Name:SLAGG, NANCY BUTLER (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:BUTLER
Last Name:SLAGG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WABASH AVE
Mailing Address - Street 2:2910
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3591
Mailing Address - Country:US
Mailing Address - Phone:312-828-0300
Mailing Address - Fax:312-828-0306
Practice Address - Street 1:405 N WABASH AVE
Practice Address - Street 2:2910
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:312-828-0300
Practice Address - Fax:312-828-0306
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.000682103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201430Medicare ID - Type Unspecified