Provider Demographics
NPI:1801386172
Name:MCNICHOLAS, MARY-MARGARET (RBT)
Entity Type:Individual
Prefix:
First Name:MARY-MARGARET
Middle Name:
Last Name:MCNICHOLAS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4617
Mailing Address - Country:US
Mailing Address - Phone:630-291-4804
Mailing Address - Fax:
Practice Address - Street 1:645 S HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4617
Practice Address - Country:US
Practice Address - Phone:630-291-4804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-47169106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician