Provider Demographics
NPI:1720235765
Name:JOHNSTON, NICOLE E (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:E
Last Name:JOHNSTON
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 1:2515 S VERONA RD
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:IL
Mailing Address - Zip Code:60479-8139
Mailing Address - Country:US
Mailing Address - Phone:815-693-0700
Mailing Address - Fax:815-693-0700
Practice Address - Street 1:850 BROOK FOREST AVE
Practice Address - Street 2:SUITE M
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8513
Practice Address - Country:US
Practice Address - Phone:815-773-9000
Practice Address - Fax:815-773-9001
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL24200099235Z00000X
IL146.009780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist