Provider Demographics
NPI:1407040736
Name:KOSTNER-NICHOLSON, TRICIA LYNN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:LYNN
Last Name:KOSTNER-NICHOLSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 POTOSI PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-4659
Mailing Address - Country:US
Mailing Address - Phone:847-370-3710
Mailing Address - Fax:
Practice Address - Street 1:2826 POTOSI PL
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-4659
Practice Address - Country:US
Practice Address - Phone:847-370-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.000388235Z00000X
COSLP.0001768235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist