Provider Demographics
NPI:1447790480
Name:GENTILLE, NICOLA
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:GENTILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 TALL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1756 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-3016
Practice Address - Country:US
Practice Address - Phone:440-724-6497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist