Provider Demographics
NPI:1942587456
Name:BEAVERS, NICOLE DESIREE (DC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DESIREE
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BURR RIDGE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0845
Mailing Address - Country:US
Mailing Address - Phone:630-920-4670
Mailing Address - Fax:630-920-4687
Practice Address - Street 1:1255 S STATE ST UNIT 6
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605
Practice Address - Country:US
Practice Address - Phone:312-880-0808
Practice Address - Fax:312-880-0810
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012045111N00000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor