Provider Demographics
NPI:1811556343
Name:NICOLAS, NICOLE L (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:NICOLAS
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 1:2019 WEALTHY ST SE APT 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3011
Mailing Address - Country:US
Mailing Address - Phone:616-828-2865
Mailing Address - Fax:
Practice Address - Street 1:2019 WEALTHY ST SE APT 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3011
Practice Address - Country:US
Practice Address - Phone:616-828-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist