Healthcare Provider Details

I. General information

NPI: 1043851843
Provider Name (Legal Business Name): HOLLEE GINDAVANH NITCHIN M.C.D., CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date: 08/10/2023
Reactivation Date: 09/06/2023

III. Provider practice location address

100 CARMEL MANOR RD.
FORT THOMAS KY
41075
US

IV. Provider business mailing address

100 CARMEL MANOR DR
FORT THOMAS KY
41075-2300
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-5111
  • Fax:
Mailing address:
  • Phone: 859-781-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: