Provider Demographics
NPI:1336315472
Name:NICHOLS, CATHERINE ANN (OTR)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:ANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9823 N PORT WASHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-6078
Mailing Address - Country:US
Mailing Address - Phone:262-643-4650
Mailing Address - Fax:
Practice Address - Street 1:6263 N GREEN BAY AVE
Practice Address - Street 2:SEVEN OAKS
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-351-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1402-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40582800Medicaid