Provider Demographics
NPI:1306177506
Name:NICHOLS, SUSAN L (OTR/L)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:WILLINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 1433
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-1433
Mailing Address - Country:US
Mailing Address - Phone:360-317-6480
Mailing Address - Fax:
Practice Address - Street 1:880 GUARD ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250
Practice Address - Country:US
Practice Address - Phone:360-317-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001892225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8929407Medicare PIN