Provider Demographics
NPI:1629397518
Name:MACDOUGALL, NICOLE M (MS OTR/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:SODEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:1449 OLD WATERBURY RD
Mailing Address - Street 2:ONE RESERVOIR OFFICE PARK, STE 104
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3926
Mailing Address - Country:US
Mailing Address - Phone:203-262-9909
Mailing Address - Fax:203-262-9911
Practice Address - Street 1:1449 OLD WATERBURY RD
Practice Address - Street 2:ONE RESERVOIR OFFICE PARK, STE 104
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3926
Practice Address - Country:US
Practice Address - Phone:203-262-9909
Practice Address - Fax:203-262-9911
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003649225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics