Provider Demographics
NPI:1679028112
Name:GOULDRUP, NICOLE LEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:GOULDRUP
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 1:378 HORSENECK RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-1337
Mailing Address - Country:US
Mailing Address - Phone:508-493-0188
Mailing Address - Fax:
Practice Address - Street 1:378 HORSENECK RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-1337
Practice Address - Country:US
Practice Address - Phone:508-493-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00842224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant