Provider Demographics
NPI:1164728713
Name:STANTON, NICOLE ELYSE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELYSE
Last Name:STANTON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9704 DOGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4760
Mailing Address - Country:US
Mailing Address - Phone:561-370-4202
Mailing Address - Fax:561-600-8438
Practice Address - Street 1:9704 DOGWOOD AVE
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4760
Practice Address - Country:US
Practice Address - Phone:561-370-4202
Practice Address - Fax:561-600-8438
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTT14475225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003308800Medicaid