Provider Demographics
NPI:1790918647
Name:BEALE -VANDYKE, NICOLE ARLETTE (CSLP-A, ITDS)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ARLETTE
Last Name:BEALE -VANDYKE
Suffix:
Gender:F
Credentials:CSLP-A, ITDS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:VANDYKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSLPA, ITDS
Mailing Address - Street 1:12485 SW 137TH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4219
Mailing Address - Country:US
Mailing Address - Phone:786-732-4922
Mailing Address - Fax:
Practice Address - Street 1:12485 SW 137TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4219
Practice Address - Country:US
Practice Address - Phone:786-732-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 390200000X, 103K00000X, 222Q00000X
FLS114252355S0801X
FLSI 14252355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSI1425OtherSPEECH PATHOLOGY ASSISTANT