Provider Demographics
NPI:1154807170
Name:BERRIO, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BERRIO
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:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-0500
Mailing Address - Country:US
Mailing Address - Phone:301-498-8100
Mailing Address - Fax:301-498-0009
Practice Address - Street 1:14409 GREENVIEW DR STE 102
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-4213
Practice Address - Country:US
Practice Address - Phone:301-498-8100
Practice Address - Fax:301-498-0009
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10567235Z00000X
MD02475L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD502165100Medicaid
MD10567OtherMARYLAND DEPT OF HEALTH