Provider Demographics
NPI:1356883714
Name:GREGG, NICOLE K (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:GREGG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 PARK LN
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6673
Mailing Address - Country:US
Mailing Address - Phone:707-372-5686
Mailing Address - Fax:
Practice Address - Street 1:3000 ALAMO DR STE 209
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6352
Practice Address - Country:US
Practice Address - Phone:707-372-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist