Provider Demographics
NPI:1134848864
Name:NICHOLSON, RYAN JAMES (OTR)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GRAMERCY PARK DR APT 418
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-4542
Mailing Address - Country:US
Mailing Address - Phone:979-255-9245
Mailing Address - Fax:
Practice Address - Street 1:3201 UNIVERSITY DR E STE 365
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3485
Practice Address - Country:US
Practice Address - Phone:979-703-1913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
478056225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist