Provider Demographics
NPI:1295276137
Name:NICHOLS, STACY (COTA/L)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7849 SAFFEL RD
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-3415
Mailing Address - Country:US
Mailing Address - Phone:573-701-5529
Mailing Address - Fax:
Practice Address - Street 1:1 GEORGIAN GARDENS DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1436
Practice Address - Country:US
Practice Address - Phone:573-438-6261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160797224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant