Provider Demographics
NPI:1801252879
Name:NICOLLE, CARRIE (MA, CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:NICOLLE
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 KRENZ AVE
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-2011
Mailing Address - Country:US
Mailing Address - Phone:815-289-4183
Mailing Address - Fax:847-516-4714
Practice Address - Street 1:653 KRENZ AVE
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2011
Practice Address - Country:US
Practice Address - Phone:815-289-4183
Practice Address - Fax:847-516-4714
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006549235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist