Provider Demographics
NPI:1225339575
Name:KANTZAVELOS, NICOLE (MACCC/SLP-L)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:KANTZAVELOS
Suffix:
Gender:F
Credentials:MACCC/SLP-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9210 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1306
Mailing Address - Country:US
Mailing Address - Phone:847-207-6290
Mailing Address - Fax:
Practice Address - Street 1:9210 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1306
Practice Address - Country:US
Practice Address - Phone:847-207-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist