Provider Demographics
NPI:1609440569
Name:DECKER, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DECKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3144 W PARK LANE DR
Mailing Address - Street 2:
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803-4534
Mailing Address - Country:US
Mailing Address - Phone:708-214-0522
Mailing Address - Fax:
Practice Address - Street 1:3144 W PARK LANE DR
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4534
Practice Address - Country:US
Practice Address - Phone:708-214-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant