Provider Demographics
NPI:1356008452
Name:SWAIN, NICOLE ELIZABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:SWAIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:SHADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2205 8TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1703
Mailing Address - Country:US
Mailing Address - Phone:717-919-6350
Mailing Address - Fax:
Practice Address - Street 1:3120 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2811
Practice Address - Country:US
Practice Address - Phone:701-839-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1885225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist