Provider Demographics
NPI:1780812636
Name:NOTOWIDIGDO, NICOLE A (MA, BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:NOTOWIDIGDO
Suffix:
Gender:
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 N CENTRAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-2943
Mailing Address - Country:US
Mailing Address - Phone:312-806-7937
Mailing Address - Fax:
Practice Address - Street 1:4801 W. PETERSON AVENUE
Practice Address - Street 2:SUITE 512
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646
Practice Address - Country:US
Practice Address - Phone:312-806-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1095773103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst