Provider Demographics
NPI:1578726634
Name:CAMPBELL-BYNUM, NICHOLLA (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLLA
Middle Name:
Last Name:CAMPBELL-BYNUM
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 1:242A ASHWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4978
Mailing Address - Country:US
Mailing Address - Phone:718-974-3757
Mailing Address - Fax:718-504-4298
Practice Address - Street 1:242A ASHWORTH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4978
Practice Address - Country:US
Practice Address - Phone:718-974-3757
Practice Address - Fax:718-504-4298
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017096-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist