Provider Demographics
NPI:1023303088
Name:ROBERTS, NICOLE RENAE (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENAE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENAE
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:7 CARNEGIE PLZ
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1000
Mailing Address - Country:US
Mailing Address - Phone:877-407-3422
Mailing Address - Fax:877-407-4329
Practice Address - Street 1:445 N VALLEY FORGE RD
Practice Address - Street 2:SUITE 118
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1239
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:877-407-4329
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011442225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist