Provider Demographics
NPI:1053881441
Name:VARVAREZOS, NICOLE (LSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VARVAREZOS
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 1:1435 E EVERGREEN DR APT 203
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-8728
Mailing Address - Country:US
Mailing Address - Phone:224-360-4093
Mailing Address - Fax:
Practice Address - Street 1:1440 RENAISSANCE DR STE 320
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1471
Practice Address - Country:US
Practice Address - Phone:847-759-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL150103135104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health