Provider Demographics
NPI:1528549920
Name:WRIGHT, NICOLE MARIE (OTD, OTR/L, CIMI)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:OTD, OTR/L, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 N CENTRAL AVE APT 546
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 ADELINE ST STE 120
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2579
Practice Address - Country:US
Practice Address - Phone:510-848-1112
Practice Address - Fax:510-848-4445
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA430625225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program