Provider Demographics
NPI:1437331428
Name:OSEQUEDA, NICOLLE ALODIA MOLINA (LICENSED MARRIAGE &)
Entity type:Individual
Prefix:MRS
First Name:NICOLLE
Middle Name:ALODIA MOLINA
Last Name:OSEQUEDA
Suffix:
Gender:F
Credentials:LICENSED MARRIAGE &
Other - Prefix:
Other - First Name:NICOLLE
Other - Middle Name:ALODIA
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARRIAGE & FAMILY TH
Mailing Address - Street 1:2755 N. PINE GROVE AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-259-2665
Mailing Address - Fax:773-248-3701
Practice Address - Street 1:2755 N. PINE GROVE AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:312-259-2665
Practice Address - Fax:773-248-3701
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 55828106H00000X
IL166000873106H00000X
CA50936106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist