Provider Demographics
NPI:1942758057
Name:ATTIVISSIMO, NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ATTIVISSIMO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PAUL REVERE LN
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1610
Mailing Address - Country:US
Mailing Address - Phone:631-902-4858
Mailing Address - Fax:
Practice Address - Street 1:72 S WOODS RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1024
Practice Address - Country:US
Practice Address - Phone:516-921-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009072224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant