Provider Demographics
NPI:1194846451
Name:BAILEY, NICOLE DAWN (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:BAILEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:NIKI
Other - Middle Name:DAWN
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:333 ARLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-8727
Mailing Address - Country:US
Mailing Address - Phone:608-588-7964
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-524-7912
Practice Address - Fax:608-524-7990
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3871-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40903400Medicaid