Provider Demographics
NPI:1063975662
Name:NICHOLLS, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATIANA
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1585 N MILWAUKEE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1359
Mailing Address - Country:US
Mailing Address - Phone:847-918-7947
Mailing Address - Fax:
Practice Address - Street 1:1585 N MILWAUKEE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1359
Practice Address - Country:US
Practice Address - Phone:847-918-7947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152000658103K00000X
106S00000X, 247200000X
IL1-24-73162103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other