Provider Demographics
NPI:1275393555
Name:MCCORRISTON, NICOLE NIEL (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:NIEL
Last Name:MCCORRISTON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10575 ALONDRA PEAK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-4651
Mailing Address - Country:US
Mailing Address - Phone:323-646-4843
Mailing Address - Fax:
Practice Address - Street 1:9121 W RUSSELL RD STE 117
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-1238
Practice Address - Country:US
Practice Address - Phone:702-499-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-3864235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist