Provider Demographics
NPI:1912145723
Name:NICHOLAS, KATHLEEN ELLISON (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELLISON
Last Name:NICHOLAS
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 1:6417 S KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-2112
Mailing Address - Country:US
Mailing Address - Phone:918-798-3196
Mailing Address - Fax:
Practice Address - Street 1:6417 S KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-2112
Practice Address - Country:US
Practice Address - Phone:918-798-3196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3390235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist