Provider Demographics
NPI:1891384772
Name:NICKERSON, MARLEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARLEE
Middle Name:
Last Name:NICKERSON
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 1:20520 WIYGUL RD
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-8879
Mailing Address - Country:US
Mailing Address - Phone:352-602-3660
Mailing Address - Fax:
Practice Address - Street 1:606 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6320
Practice Address - Country:US
Practice Address - Phone:352-805-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18011224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant