Provider Demographics
NPI:1306988662
Name:THEOFRASTOUS, NANCY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:THEOFRASTOUS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:SEELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 7TH AVENUE
Mailing Address - Street 2:SUITE 255
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-8875
Mailing Address - Country:US
Mailing Address - Phone:440-284-0775
Mailing Address - Fax:440-285-2091
Practice Address - Street 1:100 7TH AVENUE
Practice Address - Street 2:SUITE 255
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-8875
Practice Address - Country:US
Practice Address - Phone:440-284-0775
Practice Address - Fax:440-285-2091
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP7439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH013018Medicaid