Provider Demographics
NPI:1982938726
Name:GRAHAM, NICOLE C (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 N ELAINE PL
Mailing Address - Street 2:APT #2R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2077
Mailing Address - Country:US
Mailing Address - Phone:847-668-5597
Mailing Address - Fax:
Practice Address - Street 1:839 W ROOSEVELT RD
Practice Address - Street 2:ATHLETIC TRAINING
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1530
Practice Address - Country:US
Practice Address - Phone:312-993-2043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-27
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960032622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer