Provider Demographics
NPI:1417189556
Name:HEINTZ, NICOLE VICTORIA (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VICTORIA
Last Name:HEINTZ
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 N RACINE AVE
Mailing Address - Street 2:2E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4261
Mailing Address - Country:US
Mailing Address - Phone:985-981-9801
Mailing Address - Fax:985-981-9801
Practice Address - Street 1:1957 W DICKENS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3934
Practice Address - Country:US
Practice Address - Phone:773-789-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103393235Z00000X
IL146011867235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist