Provider Demographics
NPI:1407231715
Name:MCDONALD, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11423 S NATOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-2131
Mailing Address - Country:US
Mailing Address - Phone:708-663-2249
Mailing Address - Fax:
Practice Address - Street 1:15010 S RAVINIA AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3162
Practice Address - Country:US
Practice Address - Phone:708-364-0580
Practice Address - Fax:708-364-0480
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2019-02-21
Deactivation Date:2018-09-14
Deactivation Code:
Reactivation Date:2019-02-21
Provider Licenses
StateLicense IDTaxonomies
IL178.010333101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional