Provider Demographics
NPI:1407126477
Name:PERTEETE, NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PERTEETE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E 59TH ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1314
Mailing Address - Country:US
Mailing Address - Phone:312-567-0676
Mailing Address - Fax:773-955-1364
Practice Address - Street 1:4437 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4333
Practice Address - Country:US
Practice Address - Phone:773-955-1364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002275224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant