Basic Information
| Provider Information | |||||||||
| NPI: | 1710923586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG-CLINE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8703 HIGHWAY 17 BYP S | ||||||||
| Address2: | SUITE I | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295757701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434571053 | ||||||||
| FaxNumber: | 8432152910 | ||||||||
| Practice Location | |||||||||
| Address1: | 8703 HIGHWAY 17 BYP S | ||||||||
| Address2: | SUITE I | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295757701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434571053 | ||||||||
| FaxNumber: | 8432152910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3868 | SC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | SA0704 | 05 | SC | MEDICAID |