Provider Demographics
NPI:1447326236
Name:KING, NICOLE MARIE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 BRASELTON HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5907
Mailing Address - Country:US
Mailing Address - Phone:678-377-9634
Mailing Address - Fax:678-377-9609
Practice Address - Street 1:3615 BRASELTON HWY STE 103
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5907
Practice Address - Country:US
Practice Address - Phone:678-377-9634
Practice Address - Fax:678-377-9609
Is Sole Proprietor?:No
Enumeration Date:2006-11-26
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000905407CMedicaid