Provider Demographics
NPI:1508564188
Name:NICHOLS, ALYSSA (MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 FURYS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-210-9380
Mailing Address - Fax:706-650-1896
Practice Address - Street 1:415 FURYS FERRY RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907
Practice Address - Country:US
Practice Address - Phone:706-210-9380
Practice Address - Fax:706-650-1896
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008722225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist