Provider Demographics
NPI:1619458585
Name:WORTH, NICOLE PANCHULA (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PANCHULA
Last Name:WORTH
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 1:5728 KYLIE CT
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9911
Mailing Address - Country:US
Mailing Address - Phone:810-348-5044
Mailing Address - Fax:
Practice Address - Street 1:3001 HILL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-2932
Practice Address - Country:US
Practice Address - Phone:419-535-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics