Provider Demographics
NPI:1013581255
Name:KERTZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KERTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 DRURY CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMSDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63627-8100
Mailing Address - Country:US
Mailing Address - Phone:573-880-3885
Mailing Address - Fax:
Practice Address - Street 1:173 DRURY CT
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-8100
Practice Address - Country:US
Practice Address - Phone:573-880-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO07171997Medicaid