Provider Demographics
NPI:1750965018
Name:NICHOLS, BAILEY (COTA/L)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W RENNER RD APT 2326
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-1355
Mailing Address - Country:US
Mailing Address - Phone:817-629-0053
Mailing Address - Fax:
Practice Address - Street 1:2001 KIRKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-1590
Practice Address - Country:US
Practice Address - Phone:817-756-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216770224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant