Provider Demographics
NPI:1174245328
Name:RUSSWURM, NICOLE SCHMOLL (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SCHMOLL
Last Name:RUSSWURM
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DENICE
Other - Last Name:SCHMOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 TLC WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-2773
Mailing Address - Country:US
Mailing Address - Phone:325-653-3200
Mailing Address - Fax:
Practice Address - Street 1:3301 TLC WAY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-2773
Practice Address - Country:US
Practice Address - Phone:325-653-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist