Provider Demographics
NPI:1902139215
Name:RACO, NICOLE M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:RACO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:RACO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:200 TYRE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7136
Mailing Address - Country:US
Mailing Address - Phone:302-454-2047
Mailing Address - Fax:302-454-5442
Practice Address - Street 1:200 TYRE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711
Practice Address - Country:US
Practice Address - Phone:302-454-2047
Practice Address - Fax:302-454-5442
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE235Z00000X
DEO1-0000857235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000025173Medicaid