Provider Demographics
NPI:1295142305
Name:SMITH, NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SMITH
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 1:505 MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:KANE
Mailing Address - State:IL
Mailing Address - Zip Code:62054-0066
Mailing Address - Country:US
Mailing Address - Phone:217-942-6849
Mailing Address - Fax:
Practice Address - Street 1:610 LOWRY ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1768
Practice Address - Country:US
Practice Address - Phone:217-285-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003551224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant