Provider Demographics
NPI:1235804436
Name:COUDRET, NICKLAUS (MSOT)
Entity Type:Individual
Prefix:
First Name:NICKLAUS
Middle Name:
Last Name:COUDRET
Suffix:
Gender:M
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 BENT TREE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8036
Mailing Address - Country:US
Mailing Address - Phone:812-319-9425
Mailing Address - Fax:
Practice Address - Street 1:401 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-4201
Practice Address - Country:US
Practice Address - Phone:314-725-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MO2021035621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist