Basic Information
| Provider Information | |||||||||
| NPI: | 1396089934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1418 YOUNGS MILL RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274069066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363249333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2526 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245402333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348369510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 8787 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 2202007677 | VA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.