Provider Demographics
NPI:1487056966
Name:REYBOK, NICOLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:REYBOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 STANFORD RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-2128
Mailing Address - Country:US
Mailing Address - Phone:701-746-2275
Mailing Address - Fax:
Practice Address - Street 1:605 STANFORD RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2128
Practice Address - Country:US
Practice Address - Phone:701-746-2275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1055235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist