Provider Demographics
NPI:1407106172
Name:POWELL, NINA TERESA (OTR/L)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:TERESA
Last Name:POWELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:TERESA
Other - Last Name:LAUCIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12313 KENTBROOK MANOR LN
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-3938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12313 KENTBROOK MANOR LN
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-3938
Practice Address - Country:US
Practice Address - Phone:919-830-9863
Practice Address - Fax:919-521-8763
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15360225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist