Healthcare Provider Details

I. General information

NPI: 1346707056
Provider Name (Legal Business Name): NICOLE ROBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 W GALENA BLVD STE 8-316
AURORA IL
60506-3255
US

IV. Provider business mailing address

10 BIRCHWOOD CT
MONTGOMERY IL
60538-2426
US

V. Phone/Fax

Practice location:
  • Phone: 630-661-7253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: