Provider Demographics
NPI:1780357459
Name:TAYLOR, NICOLE REDD (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:REDD
Last Name:TAYLOR
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 1:1092 E MAIN ST APT 19
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4436
Mailing Address - Country:US
Mailing Address - Phone:949-544-8851
Mailing Address - Fax:
Practice Address - Street 1:1092 E MAIN ST APT 19
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4436
Practice Address - Country:US
Practice Address - Phone:949-544-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16054235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist