Provider Demographics
NPI:1164092771
Name:MCCLAIN, NICOLE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LARKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:3420 HARRY S TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-4046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3420 HARRY S TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-4046
Practice Address - Country:US
Practice Address - Phone:636-926-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-26
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021024254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507265809Medicaid
MO856118104Medicaid