Provider Demographics
NPI:1992058317
Name:NIELSON, DENISE (SLP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:NIELSON
Suffix:
Gender:
Credentials:SLP
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:SHIFFLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:77 NEALY AVENUE
Mailing Address - Street 2:633D MEDICAL GROUP
Mailing Address - City:JOINT BASE LANGLEY-EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23365-2040
Mailing Address - Country:US
Mailing Address - Phone:757-225-9816
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVENUE
Practice Address - Street 2:633D MEDICAL GROUP
Practice Address - City:JOINT BASE LANGLEY-EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23365-2040
Practice Address - Country:US
Practice Address - Phone:757-225-7630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004457235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09136101OtherASHA