Provider Demographics
NPI:1699245290
Name:WHITE, NICOLE M (OT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WHITE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-6426
Mailing Address - Country:US
Mailing Address - Phone:903-882-6400
Mailing Address - Fax:903-882-6404
Practice Address - Street 1:616 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-6426
Practice Address - Country:US
Practice Address - Phone:903-882-6400
Practice Address - Fax:903-882-6404
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113521225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist