Provider Demographics
NPI:1194953430
Name:NICOLAS, MICHELLE KAYE F (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELLE KAYE
Middle Name:F
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MICHELLE KAYE
Other - Middle Name:V
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:816 LINDA MAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 CASTRO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1010
Practice Address - Country:US
Practice Address - Phone:415-600-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05555225XN1300X
CA9820225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9820OtherOTR/L