Provider Demographics
NPI:1992322671
Name:BORN, NICOLETTE ANGELINA (MS-CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:ANGELINA
Last Name:BORN
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:ANGELINA
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS-CCC-SLP
Mailing Address - Street 1:3133 TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15129-9434
Mailing Address - Country:US
Mailing Address - Phone:724-710-8907
Mailing Address - Fax:
Practice Address - Street 1:2112 N FRANKLIN DR STE 4-5
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-5874
Practice Address - Country:US
Practice Address - Phone:724-705-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19218235Z00000X
PASL015209235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14334997OtherAMERICAN SPEECH LANGUAGE HEARING ASSOCIATION
FLSA19218OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH
PASL015209OtherCOMMONWEALTH OF PA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL