Provider Demographics
NPI:1003599077
Name:BARRY, NICHOLAS PRESTON (LSW)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PRESTON
Last Name:BARRY
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16730 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2951
Mailing Address - Country:US
Mailing Address - Phone:708-517-3120
Mailing Address - Fax:
Practice Address - Street 1:20550 S LA GRANGE RD STE 105
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1273
Practice Address - Country:US
Practice Address - Phone:331-758-7354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YP1600X
IL150.111555104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral