Provider Demographics
NPI:1114327889
Name:NICANDRO, MARA (NMT, LMT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:NICANDRO
Suffix:
Gender:F
Credentials:NMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 W NORTH AVE
Mailing Address - Street 2:ELEMENTAL HEALTH
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5429
Mailing Address - Country:US
Mailing Address - Phone:312-451-5771
Mailing Address - Fax:
Practice Address - Street 1:2225 W NORTH AVE
Practice Address - Street 2:ELEMENTAL HEALTH
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5429
Practice Address - Country:US
Practice Address - Phone:312-451-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.013372174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist