Provider Demographics
NPI:1831261593
Name:NILAN, COLLEEN M (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:NILAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MAE
Other - Last Name:TYRRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:317 FERN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4041
Mailing Address - Country:US
Mailing Address - Phone:207-212-3296
Mailing Address - Fax:207-990-4819
Practice Address - Street 1:797 WILSON ST STE 2
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1003
Practice Address - Country:US
Practice Address - Phone:207-947-8493
Practice Address - Fax:207-990-4819
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP898235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME024708OtherANTHEM
ME235550099Medicaid
206504Medicare PIN