Basic Information
| Provider Information | |||||||||
| NPI: | 1669605218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIDDAM | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12387 CLEARFALLS DR | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334284846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618527830 | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 NW 4TH ST | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334323826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613918444 | ||||||||
| FaxNumber: | 5613916823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2009 | ||||||||
| LastUpdateDate: | 08/31/2009 | ||||||||
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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 | 235Z00000X | SA9810 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | SA9810 | 01 | FL | SPEECH LICENSE | OTHER |