MEDICARE: NICOLE THOMA CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	528859	MN

General Provider Information

NPI Number	:	1457172520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE THOMA CCC-SLP

Provider Business Mailing Address
First Line	:	3485 WILLOW LAKE BLVD STE 300
Second Line	:
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5155
Country	:	US
Telephone Number	:	651-797-4430
Fax Number	:

Provider Business Practice Location Address
First Line	:	3485 WILLOW LAKE BLVD STE 300
Second Line	:
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5155
Country	:	US
Telephone Number	:	651-797-4430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2024
Last Update Date	:	10/22/2024

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Directions to “ NICOLE THOMA CCC-SLP” Practice Location

Language	Start Address	Practice Location

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