Provider Demographics
NPI:1528305398
Name:VANDERVOORT, NICOLE L (MA CCC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:VANDERVOORT
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 N HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4369
Mailing Address - Country:US
Mailing Address - Phone:312-266-8133
Mailing Address - Fax:773-528-0013
Practice Address - Street 1:2043 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4369
Practice Address - Country:US
Practice Address - Phone:312-266-8133
Practice Address - Fax:773-528-0013
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146000845235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist