Provider Demographics
NPI:1760765184
Name:NICK, HEATHER ANNE (MCD)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANNE
Last Name:NICK
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MOONTIDE CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7640
Mailing Address - Country:US
Mailing Address - Phone:803-796-5373
Mailing Address - Fax:
Practice Address - Street 1:112 MOONTIDE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7640
Practice Address - Country:US
Practice Address - Phone:803-796-5373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist