Provider Demographics
NPI:1932643202
Name:BROGHAMMER, NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROGHAMMER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SPERFSLAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:4121 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2628
Mailing Address - Country:US
Mailing Address - Phone:563-583-4003
Mailing Address - Fax:563-265-5789
Practice Address - Street 1:4121 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2628
Practice Address - Country:US
Practice Address - Phone:563-583-4003
Practice Address - Fax:563-265-5789
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA080963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665950Medicaid