Provider Demographics
NPI:1659835353
Name:SANDERS, NICOLE ANTOINETTE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANTOINETTE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:ANTOINETTE
Other - Last Name:GLAZED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:108 NORTHEAST AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:PA
Mailing Address - Zip Code:17268-2529
Mailing Address - Country:US
Mailing Address - Phone:717-504-3145
Mailing Address - Fax:
Practice Address - Street 1:9701 VEIRS DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3414
Practice Address - Country:US
Practice Address - Phone:301-424-9560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02236224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant