Provider Demographics
NPI:1255974408
Name:GEORGE, NISHA
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:GEORGE
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 1:1322 COMMONWEALTH AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-3913
Mailing Address - Country:US
Mailing Address - Phone:936-465-7367
Mailing Address - Fax:
Practice Address - Street 1:1266 FURNACE BROOK PKWY STE 100B
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4789
Practice Address - Country:US
Practice Address - Phone:617-433-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77237-SP-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist