Provider Demographics
NPI:1326317405
Name:BASILE, NICOLE (SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BASILE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LAROCCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:155 OLD WILLETS PATH
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:516-851-7022
Mailing Address - Fax:
Practice Address - Street 1:960 HASTINGS STREET
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510
Practice Address - Country:US
Practice Address - Phone:516-434-6000
Practice Address - Fax:516-494-6803
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011102-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist