Provider Demographics
NPI:1568092203
Name:RICHARDSON, NICOLE JOAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOAN
Last Name:RICHARDSON
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:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:502-882-9379
Mailing Address - Fax:502-805-0526
Practice Address - Street 1:2121 WILLOW ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-5355
Practice Address - Country:US
Practice Address - Phone:812-882-1141
Practice Address - Fax:812-255-0045
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.013428225X00000X
IN31007705A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist