MEDICARE: MS. NICOLE L NICOLAS MS, 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		MI

General Provider Information

NPI Number	:	1811556343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE L NICOLAS MS, CCC-SLP

Provider Business Mailing Address
First Line	:	2019 WEALTHY ST SE APT 2
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-3011
Country	:	US
Telephone Number	:	616-828-2865
Fax Number	:

Provider Business Practice Location Address
First Line	:	2019 WEALTHY ST SE APT 2
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-3011
Country	:	US
Telephone Number	:	616-828-2865
Fax Number	:

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

Provider Enumeration Date	:	06/09/2019
Last Update Date	:	03/24/2020

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Directions to “ MS. NICOLE L NICOLAS MS, CCC-SLP” Practice Location

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