Provider Demographics
NPI:1700014347
Name:MARIANO, NICHOLAS ANTHONY (MOT; OTR/L)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:MARIANO
Suffix:
Gender:M
Credentials:MOT; OTR/L
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:ANTHONY
Other - Last Name:MARIANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2707 BIDWELL ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-0369
Mailing Address - Country:US
Mailing Address - Phone:530-574-0864
Mailing Address - Fax:
Practice Address - Street 1:5270 ELVAS AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-2332
Practice Address - Country:US
Practice Address - Phone:530-574-0864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3310225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist