Provider Demographics
NPI:1699430280
Name:NICHOLS OCCUPATIONAL THERAPY PLLC
Entity type:Organization
Organization Name:NICHOLS OCCUPATIONAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:VITALE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MSOT, OTR/L
Authorized Official - Phone:601-850-7634
Mailing Address - Street 1:29 SUSIE B LAW RD
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-9710
Mailing Address - Country:US
Mailing Address - Phone:601-850-7634
Mailing Address - Fax:360-368-6227
Practice Address - Street 1:29 SUSIE B LAW RD
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-9710
Practice Address - Country:US
Practice Address - Phone:601-850-7634
Practice Address - Fax:360-368-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-08
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02870784Medicaid