Provider Demographics
NPI:1376775346
Name:SHEA-SCANLAN, NICOLE K (SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:SHEA-SCANLAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:SCANLAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLP
Mailing Address - Street 1:40 HENRIETTA BLVD
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-1111
Mailing Address - Country:US
Mailing Address - Phone:518-843-3003
Mailing Address - Fax:518-843-3003
Practice Address - Street 1:40 HENRIETTA BLVD
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1111
Practice Address - Country:US
Practice Address - Phone:518-843-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY020410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1376775346Medicaid