Provider Demographics
NPI:1952885972
Name:WILSON, NICOLLE DANIELLE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:DANIELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 CHANNING WAY APT 13
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2647
Mailing Address - Country:US
Mailing Address - Phone:913-461-1070
Mailing Address - Fax:
Practice Address - Street 1:1106 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-3042
Practice Address - Country:US
Practice Address - Phone:913-461-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist