Provider Demographics
NPI:1558804286
Name:RESTIVO, NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RESTIVO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10124 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5504
Mailing Address - Country:US
Mailing Address - Phone:718-241-1300
Mailing Address - Fax:
Practice Address - Street 1:10124 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5504
Practice Address - Country:US
Practice Address - Phone:718-241-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016724-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist