Provider Demographics
NPI:1093494114
Name:MOURER, NICOLETTE SUE (OT-A)
Entity Type:Individual
Prefix:MRS
First Name:NICOLETTE
Middle Name:SUE
Last Name:MOURER
Suffix:
Gender:F
Credentials:OT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2364 HIGHWAY 65 S
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-7400
Mailing Address - Country:US
Mailing Address - Phone:574-249-2498
Mailing Address - Fax:
Practice Address - Street 1:3917 KEENER LN
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-7522
Practice Address - Country:US
Practice Address - Phone:870-302-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002317A224Z00000X
TX217730224Z00000X
NC15631224Z00000X
FLOTA19300224Z00000X
SC5499224Z00000X
AROT-A1950224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant