Provider Demographics
NPI:1295449262
Name:BARTAK, NICOLLE CORA
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:CORA
Last Name:BARTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8N595 GINGERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124
Mailing Address - Country:US
Mailing Address - Phone:224-730-8543
Mailing Address - Fax:
Practice Address - Street 1:8N595 GINGERWOOD LN
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124
Practice Address - Country:US
Practice Address - Phone:224-730-8543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL173976622Medicaid