Healthcare Provider Details

I. General information

NPI: 1417270927
Provider Name (Legal Business Name): NICOLE MARCUS MS CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2138 BRUNSWICK AVE
LAWRENCEVILLE NJ
08648-4405
US

IV. Provider business mailing address

2138 BRUNSWICK AVE
LAWRENCEVILLE NJ
08648-4405
US

V. Phone/Fax

Practice location:
  • Phone: 609-392-7510
  • Fax:
Mailing address:
  • Phone: 609-392-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS00270100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: