Provider Demographics
NPI:1770790966
Name:GREGORY, NICOLE VANESSA (M ED CCC - SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:VANESSA
Last Name:GREGORY
Suffix:
Gender:F
Credentials:M ED CCC - SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 WILTON CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-4910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1565 SAXON BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-5876
Practice Address - Country:US
Practice Address - Phone:386-851-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8308235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist