Provider Demographics
NPI:1699089276
Name:CARLSON, NICOLE LYNN (MHS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MHS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9594 LEE PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7458
Mailing Address - Country:US
Mailing Address - Phone:219-384-6295
Mailing Address - Fax:219-365-5857
Practice Address - Street 1:9594 LEE PL
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7458
Practice Address - Country:US
Practice Address - Phone:219-384-6295
Practice Address - Fax:219-365-5857
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005059A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist