Provider Demographics
NPI:1740510916
Name:DEVRIES, NICHOLAS HENRY
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:HENRY
Last Name:DEVRIES
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 1:6339 N GLENWOOD AVE
Mailing Address - Street 2:#3N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1303
Mailing Address - Country:US
Mailing Address - Phone:773-260-2689
Mailing Address - Fax:
Practice Address - Street 1:6339 N. GLENWOOOD AVENUE
Practice Address - Street 2:#3N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:773-260-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12030909252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency