Provider Demographics
NPI:1811127160
Name:GRODSKI, NICOLE MICHELE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MICHELE
Last Name:GRODSKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-1079
Mailing Address - Country:US
Mailing Address - Phone:631-369-4053
Mailing Address - Fax:
Practice Address - Street 1:11 CENTER DR
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1079
Practice Address - Country:US
Practice Address - Phone:631-369-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009979-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics