Provider Demographics
NPI:1568873644
Name:TETRAULT, NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TETRAULT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 HIGHWAY 96 W STE 300
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-1961
Mailing Address - Country:US
Mailing Address - Phone:651-451-3016
Mailing Address - Fax:
Practice Address - Street 1:490 HIGHWAY 96 W STE 300
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-1961
Practice Address - Country:US
Practice Address - Phone:651-451-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MN104647225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN200603998Medicaid