Provider Demographics
NPI:1881012565
Name:GLENN, NICOLE MARIE (MS, CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:GLENN
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1806 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-3912
Practice Address - Country:US
Practice Address - Phone:610-393-7289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL011503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist