Provider Demographics
NPI:1093015570
Name:SAMUEL, NICOLE D (OT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:SAMUEL
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 1:375 AMAZON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1148
Mailing Address - Country:US
Mailing Address - Phone:815-822-4592
Mailing Address - Fax:
Practice Address - Street 1:400 N ERIE HWY
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-4263
Practice Address - Country:US
Practice Address - Phone:513-887-3710
Practice Address - Fax:360-425-1053
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR274950174400000X
225X00000X
WAOT60189012174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist