Provider Demographics
NPI:1265599955
Name:NOLAN, COLLEEN MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 KING EDWARD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4627
Mailing Address - Country:US
Mailing Address - Phone:858-354-0453
Mailing Address - Fax:
Practice Address - Street 1:129 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4509
Practice Address - Country:US
Practice Address - Phone:803-980-4900
Practice Address - Fax:803-980-4902
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6995235Z00000X
NC9913235Z00000X
CA15227235Z00000X
SC5632235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12407831OtherCAQH
NC7413745Medicaid