Provider Demographics
NPI:1396982054
Name:VIGIL-OLSIN, NICOLE RENEE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:VIGIL-OLSIN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:R
Other - Last Name:VIGIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1930 WILSHIRE BLVD STE 904
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3619
Mailing Address - Country:US
Mailing Address - Phone:213-353-9019
Mailing Address - Fax:213-353-0336
Practice Address - Street 1:1930 WILSHIRE BLVD STE 904
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3619
Practice Address - Country:US
Practice Address - Phone:213-353-9019
Practice Address - Fax:213-353-0336
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 11518235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4800836Medicare PIN