Provider Demographics
NPI:1245711548
Name:DEWEY, NICOLE LYNN (OT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:DEWEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18071 VIRGINIA CIR
Mailing Address - Street 2:
Mailing Address - City:INTERLOCHEN
Mailing Address - State:MI
Mailing Address - Zip Code:49643-8604
Mailing Address - Country:US
Mailing Address - Phone:989-529-1354
Mailing Address - Fax:
Practice Address - Street 1:1000 PAVILLIONS CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3198
Practice Address - Country:US
Practice Address - Phone:231-932-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007843225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist