Provider Demographics
NPI:1669441804
Name:GENTILE, NICHOLAS JOSEPH (OTRL)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:GENTILE
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 EICHELBERGER ST
Mailing Address - Street 2:STE 5
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331
Mailing Address - Country:US
Mailing Address - Phone:717-646-0440
Mailing Address - Fax:717-646-0444
Practice Address - Street 1:1010 EICHELBERGER ST
Practice Address - Street 2:STE 5
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331
Practice Address - Country:US
Practice Address - Phone:717-646-0440
Practice Address - Fax:717-646-0444
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02904200OtherCAPITAL BC
PA1323140001OtherMEDICARE DME
PA544310OtherMAMSI
PAS80122Medicaid
PAS80122Medicaid
PA108615Medicare PIN