Provider Demographics
NPI:1649766965
Name:KANTOLA, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:KANTOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 HURONVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2949
Mailing Address - Country:US
Mailing Address - Phone:734-887-8635
Mailing Address - Fax:734-213-7077
Practice Address - Street 1:355 HURONVIEW BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2949
Practice Address - Country:US
Practice Address - Phone:734-887-8635
Practice Address - Fax:734-213-7077
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008117225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist