MEDICARE: NICOLE WINTERS 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	58 024979	NY

General Provider Information

NPI Number	:	1417323502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE WINTERS CCC-SLP

Provider Business Mailing Address
First Line	:	7 MANCHESTER DR
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-1019
Country	:	US
Telephone Number	:	516-972-0684
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 MANCHESTER DR
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-1019
Country	:	US
Telephone Number	:	516-972-0684
Fax Number	:

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

Provider Enumeration Date	:	08/12/2015
Last Update Date	:	08/12/2015

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Directions to “ NICOLE WINTERS CCC-SLP” Practice Location

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