Healthcare Provider Details

I. General information

NPI: 1205135753
Provider Name (Legal Business Name): WILSON NICE M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BEKAH WILSON NICE M.A., CCC-SLP

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARQUETTE AVE NW STE 1200
ALBUQUERQUE NM
87102-5312
US

IV. Provider business mailing address

409 N CALIFORNIA ST
SOCORRO NM
87801-4208
US

V. Phone/Fax

Practice location:
  • Phone: 505-358-9946
  • Fax: 833-455-8353
Mailing address:
  • Phone: 505-358-9946
  • Fax: 833-448-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number15254
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5194
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: