Provider Demographics
NPI:1659854263
Name:NICKSIC, NICOLE ANNETTE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNETTE
Last Name:NICKSIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7538 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-3046
Mailing Address - Country:US
Mailing Address - Phone:219-902-4182
Mailing Address - Fax:
Practice Address - Street 1:2906 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1631
Practice Address - Country:US
Practice Address - Phone:219-513-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist