Healthcare Provider Details

I. General information

NPI: 1104240233
Provider Name (Legal Business Name): NICOLE E GEORGE MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 LEBANON RD
CLARKSVILLE OH
45113-8326
US

IV. Provider business mailing address

2380 LEBANON RD
CLARKSVILLE OH
45113-8326
US

V. Phone/Fax

Practice location:
  • Phone: 937-289-2515
  • Fax:
Mailing address:
  • Phone: 937-289-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6068
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: