Provider Demographics
NPI:1750167508
Name:BOUKYDIS, NIKOLETA NINETTE (CLINCAL PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:NIKOLETA
Middle Name:NINETTE
Last Name:BOUKYDIS
Suffix:
Gender:F
Credentials:CLINCAL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6561 W SCHOOL ST APT 308
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2996
Mailing Address - Country:US
Mailing Address - Phone:131-228-5733
Mailing Address - Fax:
Practice Address - Street 1:6561 W SCHOOL ST APT 308
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2996
Practice Address - Country:US
Practice Address - Phone:131-228-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005130101YP2500X
IL071006904103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty