Provider Demographics
NPI:1912481193
Name:NICHOLS, THERESA (COTA/L)
Entity Type:Individual
Prefix:
First Name:THERESA
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 1:317 BEVERLY PL
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:DE
Mailing Address - Zip Code:19809-2907
Mailing Address - Country:US
Mailing Address - Phone:302-593-2132
Mailing Address - Fax:
Practice Address - Street 1:2600 COMPASS RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8001
Practice Address - Country:US
Practice Address - Phone:302-764-7268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU20000966224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant