Provider Demographics
NPI:1841611720
Name:DERBY, NICOLE R (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:DERBY
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 1:3000 RICHMOND AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-3188
Mailing Address - Country:US
Mailing Address - Phone:832-298-3819
Mailing Address - Fax:
Practice Address - Street 1:3000 RICHMOND AVE STE 240
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-3188
Practice Address - Country:US
Practice Address - Phone:281-823-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103677235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist