Provider Demographics
NPI:1174839393
Name:BERRY, NICOLE CHRISTINE (MS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8004 SOUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROTHSCHILD
Mailing Address - State:WI
Mailing Address - Zip Code:54474-1300
Mailing Address - Country:US
Mailing Address - Phone:715-359-7220
Mailing Address - Fax:
Practice Address - Street 1:3401 CRANBERRY BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5217
Practice Address - Country:US
Practice Address - Phone:715-393-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3409-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist