Provider Demographics
NPI:1982211041
Name:STRACK, NINA
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:STRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2343 W MAIN ST APT 2082
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-9011
Mailing Address - Country:US
Mailing Address - Phone:860-838-1954
Mailing Address - Fax:
Practice Address - Street 1:2343 W MAIN ST APT 2082
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-9011
Practice Address - Country:US
Practice Address - Phone:860-838-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA125742355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant