Provider Demographics
NPI:1932234721
Name:SHOOK, NICOLE S (MA, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:S
Last Name:SHOOK
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 1:4470 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1980
Mailing Address - Country:US
Mailing Address - Phone:317-331-1898
Mailing Address - Fax:
Practice Address - Street 1:4470 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1980
Practice Address - Country:US
Practice Address - Phone:317-331-1898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004116A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200679640Medicaid