Provider Demographics
NPI:1154043479
Name:WILLIAMS, NICKY LEE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICKY
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 AXIS DR APT 206
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0095
Mailing Address - Country:US
Mailing Address - Phone:502-817-4157
Mailing Address - Fax:
Practice Address - Street 1:1201 E HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9788
Practice Address - Country:US
Practice Address - Phone:502-222-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20093235Z00000X
KY264275235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist