Provider Demographics
NPI:1154797611
Name:STIDHAM, NIKKI SUMMERVILLE (COTA/L)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:SUMMERVILLE
Last Name:STIDHAM
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 1:8 TWIN PEAK DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY ISLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72631-4233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3105
Practice Address - Country:US
Practice Address - Phone:870-423-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A952224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206702795Medicaid