Provider Demographics
NPI:1164655288
Name:GROSSNICKLE, CAROLYN M (OTR)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:M
Last Name:GROSSNICKLE
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 1:3201 MOOHEAU AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-1219
Mailing Address - Country:US
Mailing Address - Phone:808-732-0402
Mailing Address - Fax:
Practice Address - Street 1:710 GREEN ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2119
Practice Address - Country:US
Practice Address - Phone:808-536-3764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-476225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist