Provider Demographics
NPI:1326793001
Name:SERAVELLO, NICOLE MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:SERAVELLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 OLD OLIVER RD
Mailing Address - Street 2:
Mailing Address - City:WALLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37886-2338
Mailing Address - Country:US
Mailing Address - Phone:239-222-9911
Mailing Address - Fax:
Practice Address - Street 1:262 CHEROKEE PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5153
Practice Address - Country:US
Practice Address - Phone:865-980-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist