Provider Demographics
NPI:1164298246
Name:NICOLL, CALEB GLEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:GLEN
Last Name:NICOLL
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 E HERMOSA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2120
Mailing Address - Country:US
Mailing Address - Phone:480-577-9493
Mailing Address - Fax:
Practice Address - Street 1:5048 E OAK ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2522
Practice Address - Country:US
Practice Address - Phone:602-629-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009425225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics