Provider Demographics
NPI:1891840419
Name:DEWITT, NICOLE (OTRL)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MARKET ST
Mailing Address - Street 2:330
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-8110
Mailing Address - Country:US
Mailing Address - Phone:440-309-7867
Mailing Address - Fax:
Practice Address - Street 1:10011 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4701
Practice Address - Country:US
Practice Address - Phone:216-791-8363
Practice Address - Fax:216-791-2539
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-006791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist