Provider Demographics
NPI:1386134708
Name:COSGROVE, NICOLE ELEANOR (COTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELEANOR
Last Name:COSGROVE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 ADDISON PARK DR NW APT 310
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-2495
Mailing Address - Country:US
Mailing Address - Phone:954-870-2762
Mailing Address - Fax:
Practice Address - Street 1:1350 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4364
Practice Address - Country:US
Practice Address - Phone:256-355-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4736224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant