Provider Demographics
NPI:1437696002
Name:NICKOLICH, MIA MARUCA
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:MARUCA
Last Name:NICKOLICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:ELIZABETH
Other - Last Name:MARUCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 PERRYMONT ROAD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237
Mailing Address - Country:US
Mailing Address - Phone:412-348-1593
Mailing Address - Fax:
Practice Address - Street 1:111 PERRYMONT RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5246
Practice Address - Country:US
Practice Address - Phone:412-348-1593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012381235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist