Provider Demographics
NPI:1245740224
Name:NICHOLSON, KELLY D (SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:D
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W MORTON ST STE 114
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-1671
Mailing Address - Country:US
Mailing Address - Phone:903-462-4085
Mailing Address - Fax:903-465-5533
Practice Address - Street 1:2300 W MORTON ST STE 114
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1671
Practice Address - Country:US
Practice Address - Phone:903-462-4085
Practice Address - Fax:903-465-5533
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15406235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15406OtherTEXAS - SLP