Provider Demographics
NPI:1417658808
Name:WARREN, NICOLE MONIQUE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MONIQUE
Last Name:WARREN
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 1:8568 W 102ND TER APT 103
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1351
Mailing Address - Country:US
Mailing Address - Phone:708-600-6058
Mailing Address - Fax:
Practice Address - Street 1:4331 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2404
Practice Address - Country:US
Practice Address - Phone:708-748-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health