Provider Demographics
NPI:1336816404
Name:COONERTY, NINA ROSE (MA)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:ROSE
Last Name:COONERTY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 DIMOND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3423
Mailing Address - Country:US
Mailing Address - Phone:831-419-2978
Mailing Address - Fax:
Practice Address - Street 1:820 BAY AVE
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2140
Practice Address - Country:US
Practice Address - Phone:831-854-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15841235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist