Provider Demographics
NPI:1225187354
Name:NICOLSON, SUSAN MARIE (OTRL)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:NICOLSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:6324 FAIRVIEW RD STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3361
Practice Address - Country:US
Practice Address - Phone:980-302-9740
Practice Address - Fax:980-302-9750
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC849225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730007OtherNSC #
NC0397730002Medicare NSC
NC2512161Medicare PIN