Healthcare Provider Details

I. General information

NPI: 1013525229
Provider Name (Legal Business Name): NICOLE M LEWIS M.S., CCC-SLP, TSSLD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EMMET AVE
STATEN ISLAND NY
10306-3851
US

IV. Provider business mailing address

115 EMMET AVE
STATEN ISLAND NY
10306-3851
US

V. Phone/Fax

Practice location:
  • Phone: 917-718-3083
  • Fax:
Mailing address:
  • Phone: 718-300-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number030687
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: