Provider Demographics
NPI:1740371798
Name:KOUTRAS, NICOLE ELEANOR (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELEANOR
Last Name:KOUTRAS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1469 LEXINGTON AVE
Mailing Address - Street 2:APT. 71
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2525
Mailing Address - Country:US
Mailing Address - Phone:917-279-2109
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:KCC3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6500
Practice Address - Country:US
Practice Address - Phone:212-241-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist