Provider Demographics
NPI:1114497047
Name:MADETKO, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MADETKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11015 191ST ST
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8201
Mailing Address - Country:US
Mailing Address - Phone:630-800-7316
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker