Provider Demographics
NPI:1841902335
Name:CRUZ, NICOLE C
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:CRUZ
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 1:3029 N NEENAH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4709 GOLF RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1231
Practice Address - Country:US
Practice Address - Phone:877-377-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL160.009707225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist