Provider Demographics
NPI:1295105955
Name:QUIRK, NICOLE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:QUIRK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:332 SPENCER ST
Mailing Address - Street 2:LOWER UNIT
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2573
Mailing Address - Country:US
Mailing Address - Phone:313-999-1667
Mailing Address - Fax:
Practice Address - Street 1:45570 MABEN RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4880
Practice Address - Country:US
Practice Address - Phone:313-999-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001873235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist