Provider Demographics
NPI:1306482716
Name:NICHOLLS, SHANNON (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NICHOLLS
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 1:28 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2737
Mailing Address - Country:US
Mailing Address - Phone:732-453-4036
Mailing Address - Fax:
Practice Address - Street 1:377 UNION AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3108
Practice Address - Country:US
Practice Address - Phone:908-725-2366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01017000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist