Provider Demographics
NPI:1033287735
Name:NICHOLLS, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62600
Mailing Address - Street 2:DEPARTMENT 1268
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70162-2600
Mailing Address - Country:US
Mailing Address - Phone:504-568-4250
Mailing Address - Fax:504-568-4249
Practice Address - Street 1:1900 GRAVIER ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2262
Practice Address - Country:US
Practice Address - Phone:504-568-4250
Practice Address - Fax:504-568-4249
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist