Provider Demographics
NPI:1023364023
Name:BRODHEAD, NICOLE ANNE (OTR)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ANNE
Last Name:BRODHEAD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W. ANDERSON LN C-100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752
Mailing Address - Country:US
Mailing Address - Phone:512-451-0961
Mailing Address - Fax:512-451-9745
Practice Address - Street 1:407 S OLD HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5310
Practice Address - Country:US
Practice Address - Phone:512-504-3035
Practice Address - Fax:512-504-9287
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114832225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist