1073076105 NPI number — MRS. NICHOLE MARIE GADDIS LCSW

Table of content: MRS. NICHOLE MARIE GADDIS LCSW (NPI 1073076105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073076105 NPI number — MRS. NICHOLE MARIE GADDIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GADDIS
Provider First Name:
NICHOLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALULLO
Provider Other First Name:
NICHOLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073076105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1S376 SUMMIT AVE STE 4C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKBROOK TERRACE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60181-3966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-424-1122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 FAIRFIELD WAY # 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-237-4446
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149.018293 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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