Provider Demographics
NPI:1982916813
Name:QUINTERO, NICOLE (PHD BCBA-D)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:QUINTERO
Suffix:
Gender:F
Credentials:PHD BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 W ROOSEVELT RD
Mailing Address - Street 2:122 DHSP, MC 727
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1316
Mailing Address - Country:US
Mailing Address - Phone:312-996-4664
Mailing Address - Fax:
Practice Address - Street 1:1640 W ROOSEVELT RD
Practice Address - Street 2:122 DHSP MC 727
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-996-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008126103TC0700X
1-10-7131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst