Provider Demographics
NPI:1700446556
Name:WILLETS, NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILLETS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15900 ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:PA
Mailing Address - Zip Code:16947-9308
Mailing Address - Country:US
Mailing Address - Phone:570-506-6551
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:15900 ROUTE 6
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:PA
Practice Address - Zip Code:16947-9308
Practice Address - Country:US
Practice Address - Phone:570-506-6551
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009391224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant