Provider Demographics
NPI:1184781510
Name:ROACHE ASHLEY, NICOLA A (PSYD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:A
Last Name:ROACHE ASHLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:NICOLA
Other - Middle Name:A
Other - Last Name:ROACHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:30 E HURON ST APT 1401
Mailing Address - Street 2:CHICAGO
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2715
Mailing Address - Country:US
Mailing Address - Phone:847-269-0069
Mailing Address - Fax:847-328-4838
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 301A
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-269-0069
Practice Address - Fax:312-746-4491
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007125103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3617849901Medicaid