Healthcare Provider Details

I. General information

NPI: 1982087151
Provider Name (Legal Business Name): NICOLE JOSEPHINE OGANOV MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE JOSEPHINE GOKHMAN MA, CCC-SLP

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OAKLAND AVE STE 303
PORT JEFFERSON NY
11777-2130
US

IV. Provider business mailing address

25 OSAGE ST
SELDEN NY
11784-2729
US

V. Phone/Fax

Practice location:
  • Phone: 201-873-1404
  • Fax:
Mailing address:
  • Phone: 201-873-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number028699
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: