Provider Demographics
NPI:1588800718
Name:NICOLETTE-WALZ, NICOLE (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:NICOLETTE-WALZ
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FOUNTAIN ST STE 109
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-1725
Mailing Address - Country:US
Mailing Address - Phone:315-858-6090
Mailing Address - Fax:315-853-3190
Practice Address - Street 1:2 FOUNTAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1725
Practice Address - Country:US
Practice Address - Phone:315-858-6090
Practice Address - Fax:315-853-3190
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010183235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist