Provider Demographics
NPI:1992041735
Name:LAROSE, NICOLE (MSR, OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LAROSE
Suffix:
Gender:F
Credentials:MSR, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 HOUSTON NORTHCUTT BLVD
Mailing Address - Street 2:SUITE C-218
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3488
Mailing Address - Country:US
Mailing Address - Phone:843-509-2642
Mailing Address - Fax:
Practice Address - Street 1:85 VINCENT DR # C
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4066
Practice Address - Country:US
Practice Address - Phone:843-509-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3326225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics