Provider Demographics
NPI:1780042721
Name:VICTOR, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:VICTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 KINGS HWY APT 4J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2042
Mailing Address - Country:US
Mailing Address - Phone:718-338-2335
Mailing Address - Fax:
Practice Address - Street 1:42-77 65TH PLACE
Practice Address - Street 2:KIDS TIME THERAPIES
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:718-429-2000
Practice Address - Fax:718-429-0057
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008642-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant