Provider Demographics
NPI:1942472980
Name:LICUDINE, NICHOLAS (PT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LICUDINE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 S CALUMET AVENUE
Mailing Address - Street 2:UNIT 1610
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4814
Mailing Address - Country:US
Mailing Address - Phone:312-613-5243
Mailing Address - Fax:
Practice Address - Street 1:1841 S CALUMET AVENUE
Practice Address - Street 2:UNIT 1610
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:312-613-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.012923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist