Provider Demographics
NPI:1528029824
Name:QUINT, NICOLE RENEE (OTRL 10954)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:QUINT
Suffix:
Gender:F
Credentials:OTRL 10954
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290370
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4346
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:4568 NW 17TH AVENUE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33309-3701
Practice Address - Country:US
Practice Address - Phone:954-772-2468
Practice Address - Fax:954-772-2468
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTRL 10954225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889980100Medicaid