Provider Demographics
NPI:1326375809
Name:ESEENMACHER, NICOLE M (SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ESEENMACHER
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 1:11701 SAN VICTORIO AVE NE
Mailing Address - Street 2:GEORGIA O'KEEFE ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5947
Mailing Address - Country:US
Mailing Address - Phone:505-293-4259
Mailing Address - Fax:
Practice Address - Street 1:11701 SAN VICTORIO AVE NE
Practice Address - Street 2:GEORGIA O'KEEFE ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-5947
Practice Address - Country:US
Practice Address - Phone:505-293-4259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC 4600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNONE ASSIGNEDMedicaid