Provider Demographics
NPI:1750705844
Name:NICHOLLS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CHRISTINE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:420 E MANHATTAN BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-1267
Mailing Address - Country:US
Mailing Address - Phone:419-671-8200
Mailing Address - Fax:
Practice Address - Street 1:2317 CASS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-3111
Practice Address - Country:US
Practice Address - Phone:419-671-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP. 10384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist