Provider Demographics
NPI:1700144482
Name:SIDWELL, NICHOLAS KEITH (OT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:KEITH
Last Name:SIDWELL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:150 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:CASTLEDALE
Practice Address - State:UT
Practice Address - Zip Code:84513
Practice Address - Country:US
Practice Address - Phone:435-381-5100
Practice Address - Fax:435-381-5099
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7166585-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist