Provider Demographics
NPI:1578780151
Name:DAWSON, NICHOLE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:L
Last Name:DAWSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S CLAY ST
Mailing Address - Street 2:SUITE 204W
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 S CLAY ST
Practice Address - Street 2:SUITE 204W
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3257
Practice Address - Country:US
Practice Address - Phone:630-789-0423
Practice Address - Fax:630-214-9611
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist