Provider Demographics
NPI:1619432036
Name:MATHIS, NICOLE ADAIR (OT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ADAIR
Last Name:MATHIS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-682-8840
Mailing Address - Fax:423-602-2028
Practice Address - Street 1:600 CHASTAIN RD NW STE 428
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3210
Practice Address - Country:US
Practice Address - Phone:770-425-6701
Practice Address - Fax:770-425-6703
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12293225X00000X
GAOT008025225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist