Provider Demographics
NPI:1912610833
Name:NICKLES, MCKAYLA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:
Last Name:NICKLES
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23144 CLARABELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4392
Mailing Address - Country:US
Mailing Address - Phone:440-503-1791
Mailing Address - Fax:
Practice Address - Street 1:1698 HIGHWAY 160 W STE 240
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8035
Practice Address - Country:US
Practice Address - Phone:704-654-8599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.006805235Z00000X
SC8354235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist