Provider Demographics
NPI:1396170999
Name:SWANSON, NICOLE (MA, OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JATHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, OTR/L
Mailing Address - Street 1:2608 COMMONS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2080
Mailing Address - Country:US
Mailing Address - Phone:706-814-4397
Mailing Address - Fax:706-854-1451
Practice Address - Street 1:2608 COMMONS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2080
Practice Address - Country:US
Practice Address - Phone:706-814-4397
Practice Address - Fax:706-854-1451
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT3354225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist