Provider Demographics
NPI:1295372944
Name:NICHOLS, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 E LEE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUDON
Mailing Address - State:TN
Mailing Address - Zip Code:37774-6440
Mailing Address - Country:US
Mailing Address - Phone:865-458-8900
Mailing Address - Fax:
Practice Address - Street 1:1432 E LEE HWY
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-6440
Practice Address - Country:US
Practice Address - Phone:865-458-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000001177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNSP0000001177OtherTN HEALTH LICENSE