Provider Demographics
NPI:1508301664
Name:CHRISTEN, NICOLE SHANNON
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHANNON
Last Name:CHRISTEN
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 1:232 TALLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-1746
Mailing Address - Country:US
Mailing Address - Phone:708-207-8981
Mailing Address - Fax:
Practice Address - Street 1:232 TALLMAN AVE
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1746
Practice Address - Country:US
Practice Address - Phone:708-207-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-16-24639103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst