Provider Demographics
NPI:1932653789
Name:THEODORIDIS, NICKI JO (MED,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICKI
Middle Name:JO
Last Name:THEODORIDIS
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 GLENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1824
Mailing Address - Country:US
Mailing Address - Phone:816-753-5459
Mailing Address - Fax:816-753-5119
Practice Address - Street 1:715 GLENRIDGE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1824
Practice Address - Country:US
Practice Address - Phone:816-753-5459
Practice Address - Fax:816-753-5119
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016009648235Z00000X
OK996235Z00000X
KS3903235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist