Provider Demographics
NPI:1518107648
Name:DAVIS, NICOLE JEANETTE (OTR)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:JEANETTE
Last Name:DAVIS
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 1:11310 HORTON RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-9497
Mailing Address - Country:US
Mailing Address - Phone:248-561-5130
Mailing Address - Fax:
Practice Address - Street 1:11310 HORTON RD
Practice Address - Street 2:
Practice Address - City:GOODRICH
Practice Address - State:MI
Practice Address - Zip Code:48438-9497
Practice Address - Country:US
Practice Address - Phone:248-561-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1360077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist