Provider Demographics
NPI:1760648190
Name:BRORSEN, NICOLEE ELANE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLEE
Middle Name:ELANE
Last Name:BRORSEN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 ADELINE ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2576
Mailing Address - Country:US
Mailing Address - Phone:510-848-1112
Mailing Address - Fax:510-848-4445
Practice Address - Street 1:3075 ADELINE ST
Practice Address - Street 2:SUITE 120
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2576
Practice Address - Country:US
Practice Address - Phone:510-848-1112
Practice Address - Fax:510-848-4445
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 1104225XP0200X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics