Provider Demographics
NPI:1326497330
Name:SPENCER, NICOLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SPENCER
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 1:522 S INDEPENDENCE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1149
Mailing Address - Country:US
Mailing Address - Phone:757-453-4899
Mailing Address - Fax:518-274-5438
Practice Address - Street 1:522 S INDEPENDENCE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1149
Practice Address - Country:US
Practice Address - Phone:757-453-4899
Practice Address - Fax:518-274-5438
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008973235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist