MEDICARE: EXPRESSIVE EDGE LLC

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

General Provider Information

NPI Number	:	1528990751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPRESSIVE EDGE LLC

Provider Business Mailing Address
First Line	:	10670 S MARYLAND PKWY STE 135
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-8713
Country	:	US
Telephone Number	:	323-646-4843
Fax Number	:	702-442-1886

Provider Business Practice Location Address
First Line	:	10670 S MARYLAND PKWY STE 135
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-8713
Country	:	US
Telephone Number	:	323-646-4843
Fax Number	:	702-442-1886

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	MRS. NICOLE NIEL MCCORRISTON
Credential	:	CCC-SLP
Telephone Number	:	323-646-4843

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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Directions to “EXPRESSIVE EDGE LLC ” Practice Location

Language	Start Address	Practice Location

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