Provider Demographics
NPI:1578338851
Name:MAZZUKI, NICOLE ALEXANDRA (MSED, CF-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRA
Last Name:MAZZUKI
Suffix:
Gender:F
Credentials:MSED, CF-SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ALEXANDRA
Other - Last Name:FAHIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSED, CF-SLP
Mailing Address - Street 1:40 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-1241
Mailing Address - Country:US
Mailing Address - Phone:347-244-3882
Mailing Address - Fax:
Practice Address - Street 1:579 CRANBURY RD STE I
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5405
Practice Address - Country:US
Practice Address - Phone:732-313-5458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTL-4309235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist