Provider Demographics
NPI:1659030484
Name:BENVENUTA, NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BENVENUTA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NEWFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:NJ
Mailing Address - Zip Code:07421-1534
Mailing Address - Country:US
Mailing Address - Phone:973-229-5987
Mailing Address - Fax:
Practice Address - Street 1:561 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:PIERMONT
Practice Address - State:NY
Practice Address - Zip Code:10968-1116
Practice Address - Country:US
Practice Address - Phone:845-680-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010985224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant