Provider Demographics
NPI:1659858959
Name:NICKELSON, HEATHER LEE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20744 KIEFER LN
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-8756
Mailing Address - Country:US
Mailing Address - Phone:636-328-1066
Mailing Address - Fax:
Practice Address - Street 1:1020 S PARKWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7704
Practice Address - Country:US
Practice Address - Phone:573-290-5799
Practice Address - Fax:573-339-0196
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017006776225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist