Provider Demographics
NPI:1134788839
Name:BENNETT, NICOLE LYN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HERKIMER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-3523
Mailing Address - Country:US
Mailing Address - Phone:443-337-3868
Mailing Address - Fax:
Practice Address - Street 1:200 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4888
Practice Address - Country:US
Practice Address - Phone:443-984-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05083235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist