Provider Demographics
NPI:1285932012
Name:GERASIMOFF, NICHOLAS PAUL (OTRL)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:GERASIMOFF
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12560 JELSO PL
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N8N4H4
Mailing Address - Country:CA
Mailing Address - Phone:519-735-1898
Mailing Address - Fax:
Practice Address - Street 1:22731 NEWMAN ST STE 100B
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2023
Practice Address - Country:US
Practice Address - Phone:313-791-0616
Practice Address - Fax:313-791-0632
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007912225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist