Provider Demographics
NPI:1194075580
Name:LEE, NICOLE R (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:LEE
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 1:3030 S JONES BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6792
Mailing Address - Country:US
Mailing Address - Phone:702-360-1137
Mailing Address - Fax:
Practice Address - Street 1:725 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-8149
Practice Address - Country:US
Practice Address - Phone:920-237-6396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1465235Z00000X
WI4044-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist