Healthcare Provider Details

I. General information

NPI: 1043788169
Provider Name (Legal Business Name): NICOLE LYNN BERKOSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 LONGHORN ST NW
CARROLLTON OH
44615-9469
US

IV. Provider business mailing address

4835 DRUMCLIFF DR NW
CANTON OH
44708-2007
US

V. Phone/Fax

Practice location:
  • Phone: 330-627-5501
  • Fax:
Mailing address:
  • Phone: 717-756-4241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12918
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: