Basic Information
| Provider Information | |||||||||
| NPI: | 1235614488 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA MONTERO | ||||||||
| FirstName: | NICOLL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 820; BUSINESS TOWER 1, | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 1351 E BARDIN RD STE 160 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760182136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177951291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2018 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 40848 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.