Provider Demographics
NPI:1659974608
Name:WALTER, NICOLE CORINNE (OTA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CORINNE
Last Name:WALTER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 RESTORATIVE LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-7662
Mailing Address - Country:US
Mailing Address - Phone:845-978-9966
Mailing Address - Fax:
Practice Address - Street 1:82 RESTORATIVE LN
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-7662
Practice Address - Country:US
Practice Address - Phone:845-978-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007487-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant