Provider Demographics
NPI:1790266856
Name:BRIM, NIKOLE S (AAS,COTA)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:S
Last Name:BRIM
Suffix:
Gender:F
Credentials:AAS,COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 LIVERPOOL LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8383
Mailing Address - Country:US
Mailing Address - Phone:214-470-0035
Mailing Address - Fax:888-371-6987
Practice Address - Street 1:320 W BELT LINE RD STE 4032ND
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2096
Practice Address - Country:US
Practice Address - Phone:214-470-0035
Practice Address - Fax:888-371-6987
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215377224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215377OtherTBOTE