Provider Demographics
NPI:1841747060
Name:TABETA, NICOLE EVA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:EVA
Last Name:TABETA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 W LELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7043
Mailing Address - Country:US
Mailing Address - Phone:773-334-7117
Mailing Address - Fax:
Practice Address - Street 1:1207 W LELAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-7043
Practice Address - Country:US
Practice Address - Phone:773-334-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional