Provider Demographics
NPI:1841418365
Name:LADOUCEUR, NICOLE LEE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEE
Last Name:LADOUCEUR
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:ZDRAVECKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:806 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-5726
Mailing Address - Country:US
Mailing Address - Phone:904-472-7057
Mailing Address - Fax:
Practice Address - Street 1:1640 REDSTONE CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7605
Practice Address - Country:US
Practice Address - Phone:435-776-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3875225X00000X
TN3556225X00000X
OH006686225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist