Provider Demographics
NPI:1457053357
Name:KOCANDA, NICOLE A (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:KOCANDA
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 1:11741 S KEDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-1729
Mailing Address - Country:US
Mailing Address - Phone:708-979-1588
Mailing Address - Fax:
Practice Address - Street 1:11741 S KEDVALE AVE
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-1729
Practice Address - Country:US
Practice Address - Phone:708-979-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14382786235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist