Provider Demographics
NPI:1467804278
Name:HETHERINGTON, NICKOLAS (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3566
Mailing Address - Country:US
Mailing Address - Phone:833-684-5439
Mailing Address - Fax:321-286-3020
Practice Address - Street 1:1900 S HARBOR CITY BLVD STE 108
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:833-684-5439
Practice Address - Fax:321-684-5439
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17856225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist