Provider Demographics
NPI:1295051019
Name:BURKHART, NICOLE RAE (COTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:BURKHART
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 1:5110 E 1000 N
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-8152
Mailing Address - Country:US
Mailing Address - Phone:260-515-7126
Mailing Address - Fax:
Practice Address - Street 1:1850 W MATADOR ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3711
Practice Address - Country:US
Practice Address - Phone:765-689-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001352A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32001352AOtherOCCUPATIONAL THERAPY ASSISTANT