Provider Demographics
NPI:1063392256
Name:MEDINA, NICOLE (LSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36163 N JAMES CT
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60041-8210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 HOLLISTER DR STE 201
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5266
Practice Address - Country:US
Practice Address - Phone:847-549-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-06
Last Update Date:2025-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.116992104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker