MEDICARE: NICOLE QUIRK M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7101001873	MI

General Provider Information

NPI Number	:	1295105955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE QUIRK M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	332 SPENCER ST
Second Line	:	LOWER UNIT
City	:	FERNDALE
State	:	MI
Zip	:	48220-2573
Country	:	US
Telephone Number	:	313-999-1667
Fax Number	:

Provider Business Practice Location Address
First Line	:	45570 MABEN RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-4880
Country	:	US
Telephone Number	:	313-999-1667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2015
Last Update Date	:	10/06/2015

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Directions to “ NICOLE QUIRK M.A., CCC-SLP” Practice Location

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