Provider Demographics
NPI:1679780035
Name:KOMIE, NICOLETTE RENEE (DEVELOPMENTAL THERAP)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:RENEE
Last Name:KOMIE
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:RENEE
Other - Last Name:POLYDOROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DEVELOPMENTAL THERAP
Mailing Address - Street 1:2912 NORWAY PINE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6425
Mailing Address - Country:US
Mailing Address - Phone:847-275-4115
Mailing Address - Fax:847-868-9222
Practice Address - Street 1:2912 NORWAY PINE LN
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-6425
Practice Address - Country:US
Practice Address - Phone:847-275-4115
Practice Address - Fax:847-868-9222
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILNP51710898P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist