Provider Demographics
NPI:1790123230
Name:MOSKALL, NICOLE ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:MOSKALL
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 1:10909 HANNAN RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1383
Mailing Address - Country:US
Mailing Address - Phone:734-893-1033
Mailing Address - Fax:
Practice Address - Street 1:10909 HANNAN RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1383
Practice Address - Country:US
Practice Address - Phone:734-893-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202001771224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant