Provider Demographics
NPI:1750617551
Name:TRAVIS, NICOLE MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RICHARD AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-3364
Mailing Address - Country:US
Mailing Address - Phone:607-343-6207
Mailing Address - Fax:
Practice Address - Street 1:1040 CONKLIN RD
Practice Address - Street 2:
Practice Address - City:CONKLIN
Practice Address - State:NY
Practice Address - Zip Code:13748-1136
Practice Address - Country:US
Practice Address - Phone:607-775-0176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015040-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist