Provider Demographics
NPI:1255637591
Name:BENNETT, NICOLE JAHNE (MS, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JAHNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS, CCC-SLP, TSSLD
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:JAHNE
Other - Last Name:KILDARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP, TSSLD
Mailing Address - Street 1:487 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-2118
Mailing Address - Country:US
Mailing Address - Phone:914-513-6860
Mailing Address - Fax:
Practice Address - Street 1:2811 QUEENS PLZ N
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4008
Practice Address - Country:US
Practice Address - Phone:917-286-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist