Provider Demographics
NPI:1376207795
Name:SEVERINO, NICKOLAS WILLIAM (DC)
Entity Type:Individual
Prefix:MR
First Name:NICKOLAS
Middle Name:WILLIAM
Last Name:SEVERINO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 MEMORIAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6267
Mailing Address - Country:US
Mailing Address - Phone:815-455-1910
Mailing Address - Fax:815-455-2541
Practice Address - Street 1:318 MEMORIAL DR STE 200
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6267
Practice Address - Country:US
Practice Address - Phone:815-455-1910
Practice Address - Fax:815-455-2541
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013758111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor