Provider Demographics
NPI:1417151614
Name:BURNS, NICOLE A (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:BURNS
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 1:31 OLD ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:105 NEWTOWN RD # A
Practice Address - Street 2:SUITE 5
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4114
Practice Address - Country:US
Practice Address - Phone:203-739-0765
Practice Address - Fax:203-739-0792
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003183225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT130003183OtherANTHEM BC
CT130003183OtherANTHEM BC