Provider Demographics
NPI:1518109446
Name:DAVIS, NICOLE M (OT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S 9TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5233
Mailing Address - Country:US
Mailing Address - Phone:215-503-6791
Mailing Address - Fax:215-923-2475
Practice Address - Street 1:130 S 9TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5233
Practice Address - Country:US
Practice Address - Phone:215-503-6791
Practice Address - Fax:215-923-2475
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA154046Medicare PIN