Provider Demographics
NPI:1306380464
Name:MASTERS, NICOLE (OTRL)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MASTERS
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 1:41743 ENTERPRISE CIR N
Mailing Address - Street 2:106
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5645
Mailing Address - Country:US
Mailing Address - Phone:951-302-0278
Mailing Address - Fax:
Practice Address - Street 1:41743 ENTERPRISE CIR N
Practice Address - Street 2:106
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5645
Practice Address - Country:US
Practice Address - Phone:951-302-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16193225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16193OtherCALIFORNIA OT LICENSE