Provider Demographics
NPI:1568240836
Name:ALTHAGE, NICOLE ALENA (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALENA
Last Name:ALTHAGE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 SHALLOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3711
Mailing Address - Country:US
Mailing Address - Phone:314-496-3820
Mailing Address - Fax:
Practice Address - Street 1:1370 SHALLOW LAKE DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3711
Practice Address - Country:US
Practice Address - Phone:314-496-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023036837224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant