Provider Demographics
NPI:1417792623
Name:NICKSON, MICHAEL (VRC, CRC, LCPC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:NICKSON
Suffix:
Gender:M
Credentials:VRC, CRC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6930 S HONORE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60636-3234
Mailing Address - Country:US
Mailing Address - Phone:773-653-1152
Mailing Address - Fax:
Practice Address - Street 1:EDWARD HINES JR. VA HOSPITAL, VRS(MC:116A7)
Practice Address - Street 2:5000 S. 5TH AVE.
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007568101YM0800X, 101YP2500X
65571225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional