Provider Demographics
NPI:1366938722
Name:WARD, NICOLE (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WARD
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 1:14 MELVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-3944
Mailing Address - Country:US
Mailing Address - Phone:609-234-6546
Mailing Address - Fax:
Practice Address - Street 1:133 EAYRESTOWN RD STE F
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08088-9122
Practice Address - Country:US
Practice Address - Phone:609-234-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00948200235Z00000X
NJ235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty