Provider Demographics
NPI:1700369592
Name:MARISCAL, NICOLE RAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:MARISCAL
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 1:17042 BELLFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-5950
Mailing Address - Country:US
Mailing Address - Phone:562-991-1324
Mailing Address - Fax:
Practice Address - Street 1:17042 BELLFLOWER BLVD
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-5950
Practice Address - Country:US
Practice Address - Phone:562-991-1324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4453224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant