Provider Demographics
NPI:1649561374
Name:HEATH, NICOLE M (PHD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:HEATH
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 1:1645 W JACKSON BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3276
Mailing Address - Country:US
Mailing Address - Phone:312-942-5932
Mailing Address - Fax:312-942-4990
Practice Address - Street 1:1645 W JACKSON BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3276
Practice Address - Country:US
Practice Address - Phone:312-942-5932
Practice Address - Fax:312-942-4990
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007997103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical