Provider Demographics
NPI:1639579204
Name:DOMINISH, NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:DOMINISH
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 1:58 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3114
Mailing Address - Country:US
Mailing Address - Phone:440-392-5495
Mailing Address - Fax:
Practice Address - Street 1:560 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3130
Practice Address - Country:US
Practice Address - Phone:440-392-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3127708235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist