Provider Demographics
NPI:1508477589
Name:AMATO, NICOLE (OTD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:AMATO
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E HURON ST APT 2707
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4706
Mailing Address - Country:US
Mailing Address - Phone:402-926-9593
Mailing Address - Fax:
Practice Address - Street 1:4619 N RAVENSWOOD AVE STE 205B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4579
Practice Address - Country:US
Practice Address - Phone:773-697-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014305225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics