Provider Demographics
NPI:1891344271
Name:CLARK, NICOLE (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5564 W ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6506
Mailing Address - Country:US
Mailing Address - Phone:847-567-1528
Mailing Address - Fax:
Practice Address - Street 1:125 FAIRFIELD WAY STE 380
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-3701
Practice Address - Country:US
Practice Address - Phone:815-295-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional