Healthcare Provider Details

I. General information

NPI: 1396489001
Provider Name (Legal Business Name): NICOLE WHITE SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10432 BALLS FORD RD STE 300
MANASSAS VA
20109-2517
US

IV. Provider business mailing address

440 N BARRANCA AVE # 9898
COVINA CA
91723-1722
US

V. Phone/Fax

Practice location:
  • Phone: 512-377-6318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202012273
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP4556
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number118263
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101010102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: