Provider Demographics
NPI:1235787540
Name:PHILLIPS, NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 LODA DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-2015
Mailing Address - Country:US
Mailing Address - Phone:513-535-3821
Mailing Address - Fax:
Practice Address - Street 1:3520 STATE ROUTE 132
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-1718
Practice Address - Country:US
Practice Address - Phone:513-535-3821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist