Provider Demographics
NPI:1790321842
Name:MCDOUGAL, NICOLE ROSE (SLP-CF)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:SLP-CF
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ROSE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2352 W OLD ROSEBUD LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8350
Mailing Address - Country:US
Mailing Address - Phone:507-259-4878
Mailing Address - Fax:
Practice Address - Street 1:527 400 N
Practice Address - Street 2:STE 2
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057
Practice Address - Country:US
Practice Address - Phone:801-714-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11540917-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist