Provider Demographics
NPI:1982971214
Name:DAVIS, NICOLE KATHERINE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:KATHERINE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 TOWN LINE RD
Mailing Address - Street 2:
Mailing Address - City:CADYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12918-1713
Mailing Address - Country:US
Mailing Address - Phone:518-293-7932
Mailing Address - Fax:
Practice Address - Street 1:609 MINER FARM RD
Practice Address - Street 2:
Practice Address - City:CHAZY
Practice Address - State:NY
Practice Address - Zip Code:12921-3003
Practice Address - Country:US
Practice Address - Phone:518-846-8885
Practice Address - Fax:518-846-8322
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013430OtherNEW YORK STATE SPEECH PATHOLOGY LICENSE
12072291OtherASHA MEMBER