Provider Demographics
NPI:1508458159
Name:NICKLAS, TAMARA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N. HAPP RD
Mailing Address - Street 2:STE 210
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 N. HAPP RD
Practice Address - Street 2:STE 210
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093
Practice Address - Country:US
Practice Address - Phone:773-492-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227017315225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist