Provider Demographics
NPI:1225515927
Name:FLUTH, NICOLE (OTD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FLUTH
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 E VILLA RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-8542
Mailing Address - Country:US
Mailing Address - Phone:605-359-3827
Mailing Address - Fax:
Practice Address - Street 1:5108 E VILLA RIDGE ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-8542
Practice Address - Country:US
Practice Address - Phone:605-359-3827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1114225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1114OtherSDBMOE STATE LICENSE