Provider Demographics
NPI:1295844603
Name:IWANOWSKI, NICOLE M (OTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:IWANOWSKI
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:GROPPI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L, CLT
Mailing Address - Street 1:600 52ND ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3423
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:10222 74TH ST
Practice Address - Street 2:SUITE 211
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-6810
Practice Address - Country:US
Practice Address - Phone:262-925-5020
Practice Address - Fax:262-925-5021
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4230026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11781771OtherCAQH
WI1295844603Medicaid
WIK400271681Medicare PIN