Provider Demographics
NPI:1033961701
Name:CUNDICK, NICOLE VICTORIA (TRT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VICTORIA
Last Name:CUNDICK
Suffix:
Gender:F
Credentials:TRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 E 5350 S
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TERRACE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6934
Mailing Address - Country:US
Mailing Address - Phone:801-645-3972
Mailing Address - Fax:
Practice Address - Street 1:375 E 5350 S
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-6934
Practice Address - Country:US
Practice Address - Phone:801-645-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT126064474003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist