Provider Demographics
NPI:1619417557
Name:PUTTICK, NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PUTTICK
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 1:5 RICHLEE RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-6016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 RICHLEE RD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-6016
Practice Address - Country:US
Practice Address - Phone:203-308-9384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-25
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004644225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004644OtherDEPARTMENT OF PUBLIC HEALTH