Provider Demographics
NPI:1255861159
Name:DWYER, NICOLE RENEE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:DWYER
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 1:750 LIDO BLVD APT 1A
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-5201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 NEW HWY
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4229
Practice Address - Country:US
Practice Address - Phone:631-858-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025449-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist