Provider Demographics
NPI:1568968568
Name:TIRRELL, NICOLE (TSLP15641)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TIRRELL
Suffix:
Gender:F
Credentials:TSLP15641
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4338 E SANDIA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3947
Mailing Address - Country:US
Mailing Address - Phone:480-773-5974
Mailing Address - Fax:
Practice Address - Street 1:9385 W DONALD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2988
Practice Address - Country:US
Practice Address - Phone:480-773-5974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP15641235Z00000X
2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist