Provider Demographics
NPI:1104390517
Name:NIVISON, WENDY (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:
Last Name:NIVISON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:JO
Other - Last Name:FRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:849 FUHRMAN MILL RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-9311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:267 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-3614
Practice Address - Country:US
Practice Address - Phone:717-633-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007933224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant