Provider Demographics
NPI:1366802704
Name:BLACKWELL, NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BLACKWELL
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 1:815 WENTWORTH DR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-7812
Mailing Address - Country:US
Mailing Address - Phone:704-796-2850
Mailing Address - Fax:
Practice Address - Street 1:815 WENTWORTH DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-7812
Practice Address - Country:US
Practice Address - Phone:704-796-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-27
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9777224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant