Provider Demographics
NPI:1780149179
Name:SWIM, NICCOLE
Entity type:Individual
Prefix:
First Name:NICCOLE
Middle Name:
Last Name:SWIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10773 W WHITEHORN WAY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-9802
Mailing Address - Country:US
Mailing Address - Phone:602-301-4760
Mailing Address - Fax:
Practice Address - Street 1:10773 W WHITEHORN WAY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-9802
Practice Address - Country:US
Practice Address - Phone:602-301-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-10
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-046621224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant