Provider Demographics
NPI:1730432519
Name:NIMMO, DEBRA ANN (SLP)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANN
Last Name:NIMMO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 NICHOLAS CT
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-4616
Mailing Address - Country:US
Mailing Address - Phone:516-931-2625
Mailing Address - Fax:
Practice Address - Street 1:3299 BELTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3362
Practice Address - Country:US
Practice Address - Phone:516-679-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005533-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005533-1OtherSPEECH-LANGUAGE PATHOLOGIST LICENSE NUMBER
NY010-715-05OtherASHA CERTIFICATION