Healthcare Provider Details

I. General information

NPI: 1710896337
Provider Name (Legal Business Name): NICOLE HEINZ MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9919 N RUSHTON RD
SOUTH LYON MI
48178-8186
US

IV. Provider business mailing address

11465 PLYMOUTH WOODS DR
LIVONIA MI
48150-2488
US

V. Phone/Fax

Practice location:
  • Phone: 248-573-8524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101009217
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: