Provider Demographics
NPI:1063885457
Name:WOLFE, NICOLE CARROLL (OT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CARROLL
Last Name:WOLFE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E PECK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7474
Mailing Address - Country:US
Mailing Address - Phone:337-780-4173
Mailing Address - Fax:
Practice Address - Street 1:206 E PECK BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7474
Practice Address - Country:US
Practice Address - Phone:337-780-4173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT200017171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor