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General NPI Number Information
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NPI Number | 1932653789
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Entity Type | Individual
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Provider Name | NICKI JO THEODORIDIS M.ED.,CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 08/10/2016
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Last Update Date | 08/10/2016
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Provider Practice Location Address
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Address Line | 715 GLENRIDGE DR
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City | EDMOND
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State | OK
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Zip | 73013-1824
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Country | US
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Telephone | 816-753-5459
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Fax | 816-753-5119
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Provider Business Mailing Address
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Address Line | 715 GLENRIDGE DR
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City | EDMOND
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State | OK
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Zip | 73013-1824
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Country | US
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Telephone | 816-753-5459
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Fax | 816-753-5119
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2016009648
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 996
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 3903
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License Number State | KS
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