Provider Demographics
NPI:1013525229
Name:LEWIS, NICOLE M (MS, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:
Credentials:MS, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:KWOKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 EMMET AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3851
Mailing Address - Country:US
Mailing Address - Phone:718-300-0655
Mailing Address - Fax:
Practice Address - Street 1:115 EMMET AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3851
Practice Address - Country:US
Practice Address - Phone:718-727-8202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030687235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist