Provider Demographics
NPI:1962832550
Name:NIETZKE, CORY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:NIETZKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5547 N RAVENSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1125
Mailing Address - Country:US
Mailing Address - Phone:773-818-0495
Mailing Address - Fax:773-769-1476
Practice Address - Street 1:5547 N RAVENSWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1125
Practice Address - Country:US
Practice Address - Phone:773-818-0495
Practice Address - Fax:773-769-1476
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0178.005724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional