Provider Demographics
NPI:1679096572
Name:MCNICHOLS, ANGELA DAWN (PSYD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:MCNICHOLS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 N GLENWOOD AVE APT GW
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2299
Mailing Address - Country:US
Mailing Address - Phone:773-456-1045
Mailing Address - Fax:
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6064
Practice Address - Country:US
Practice Address - Phone:773-344-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009457103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical