Provider Demographics
NPI:1407339138
Name:PETERS, NICOLE JOY
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JOY
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 GARDENDALE ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3529
Mailing Address - Country:US
Mailing Address - Phone:210-615-7837
Mailing Address - Fax:
Practice Address - Street 1:5705 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78108-2003
Practice Address - Country:US
Practice Address - Phone:210-379-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19725OtherSTATE LICENSE FOR SPEECH PATHOLOGY