Provider Demographics
NPI:1790505980
Name:MICHICICH, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MICHICICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8407
Mailing Address - Country:US
Mailing Address - Phone:312-243-8487
Mailing Address - Fax:
Practice Address - Street 1:140 E LOOP RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-8407
Practice Address - Country:US
Practice Address - Phone:312-243-8487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician