Provider Demographics
NPI:1609323492
Name:FOX, NICOLE A (CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:A
Last Name:FOX
Suffix:
Gender:F
Credentials:CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 W 14TH RD
Mailing Address - Street 2:
Mailing Address - City:BROAD CHANNEL
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 W 14TH RD
Practice Address - Street 2:
Practice Address - City:BROAD CHANNEL
Practice Address - State:NY
Practice Address - Zip Code:11693-1138
Practice Address - Country:US
Practice Address - Phone:917-748-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY027559-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist