Provider Demographics
NPI:1255835567
Name:HANNEKEN ONTIS, NICHOLE RAE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:RAE
Last Name:HANNEKEN ONTIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:RAE
Other - Last Name:HANNEKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 CHAFFER AVE
Mailing Address - Street 2:
Mailing Address - City:ROXANA
Mailing Address - State:IL
Mailing Address - Zip Code:62084-1125
Mailing Address - Country:US
Mailing Address - Phone:618-254-7369
Mailing Address - Fax:
Practice Address - Street 1:401 CHAFFER AVE
Practice Address - Street 2:
Practice Address - City:ROXANA
Practice Address - State:IL
Practice Address - Zip Code:62084-1125
Practice Address - Country:US
Practice Address - Phone:618-254-7369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010146235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty