Provider Demographics
NPI:1962952259
Name:NICHOLSON, ELIZABETH (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 ROSEDALE RD NE
Mailing Address - Street 2:LOWER UNIT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4827
Mailing Address - Country:US
Mailing Address - Phone:678-488-0589
Mailing Address - Fax:
Practice Address - Street 1:915 ROSEDALE RD NE
Practice Address - Street 2:LOWER UNIT
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4827
Practice Address - Country:US
Practice Address - Phone:678-488-0589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist