Provider Demographics
NPI:1407390644
Name:MACAK, NICHOLAS ALBERT
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALBERT
Last Name:MACAK
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 1:301 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2899
Mailing Address - Country:US
Mailing Address - Phone:815-717-1700
Mailing Address - Fax:
Practice Address - Street 1:301 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2899
Practice Address - Country:US
Practice Address - Phone:815-717-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8422752Medicaid