Provider Demographics
NPI:1548783665
Name:CIANCHETTI, NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CIANCHETTI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 AUBURN AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3767 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1040
Practice Address - Country:US
Practice Address - Phone:716-874-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP07090225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP07090OtherLIMITED PERMIT