Provider Demographics
NPI:1851445100
Name:NICOLOFF, MARA JOI (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:JOI
Last Name:NICOLOFF
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 W MORSE AVE
Mailing Address - Street 2:#3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3517
Mailing Address - Country:US
Mailing Address - Phone:773-274-4892
Mailing Address - Fax:
Practice Address - Street 1:1211 W MORSE AVE
Practice Address - Street 2:#3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3517
Practice Address - Country:US
Practice Address - Phone:773-274-4892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist