Provider Demographics
NPI:1811618101
Name:BERGHORST, NICOLE DANIELLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:BERGHORST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11425 MAGNOLIA AVE APT 67
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-4879
Mailing Address - Country:US
Mailing Address - Phone:209-613-7605
Mailing Address - Fax:
Practice Address - Street 1:661 SIMEON CT
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-9566
Practice Address - Country:US
Practice Address - Phone:209-613-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73762355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant