Provider Demographics
NPI:1811291057
Name:TEATER, NICOLE MARIE (COTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:TEATER
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 1:945 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2376
Mailing Address - Country:US
Mailing Address - Phone:386-956-3380
Mailing Address - Fax:
Practice Address - Street 1:500 GRAND PLAZA DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7900
Practice Address - Country:US
Practice Address - Phone:386-775-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 11355224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant