Provider Demographics
NPI:1083063002
Name:VAN DYCKE, NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VAN DYCKE
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 1:7015 EDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8335
Mailing Address - Country:US
Mailing Address - Phone:815-353-0068
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.0038952355S0801X
WI5023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant