Provider Demographics
NPI:1396261400
Name:CESTRO, NICOLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CESTRO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 HARVARD LN
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3528
Mailing Address - Country:US
Mailing Address - Phone:516-554-1065
Mailing Address - Fax:
Practice Address - Street 1:1225 FRANKLIN AVE STE 325
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1693
Practice Address - Country:US
Practice Address - Phone:516-512-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03858055Medicaid