Provider Demographics
NPI:1356817316
Name:MASTERS, NICOLE LEE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:MASTERS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 L ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5017
Mailing Address - Country:US
Mailing Address - Phone:916-601-6268
Mailing Address - Fax:
Practice Address - Street 1:1964 11TH AVE
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-4532
Practice Address - Country:US
Practice Address - Phone:530-741-6194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP21534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist