Provider Demographics
NPI:1174193270
Name:DEBERRY, NICOLE A
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:DEBERRY
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 1:1403 HILLSIDE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2408
Mailing Address - Country:US
Mailing Address - Phone:480-225-3133
Mailing Address - Fax:
Practice Address - Street 1:3709 GROOMS ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1626
Practice Address - Country:US
Practice Address - Phone:305-905-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist