Provider Demographics
NPI:1033311022
Name:CLEMENTS, NICOLE DANIELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DANIELLE
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-5721
Mailing Address - Country:US
Mailing Address - Phone:540-961-1034
Mailing Address - Fax:
Practice Address - Street 1:2603 WARM HEARTH DR
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6287
Practice Address - Country:US
Practice Address - Phone:540-552-3176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003735235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist