Provider Demographics
NPI:1356902100
Name:WILKERSON, NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILKERSON
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 1:222 LADEAN CT STE E
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7504
Mailing Address - Country:US
Mailing Address - Phone:864-558-7519
Mailing Address - Fax:
Practice Address - Street 1:222 LADEAN CT STE E
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-7504
Practice Address - Country:US
Practice Address - Phone:645-587-5198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-19-89795106S00000X
SC.6669225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician