Provider Demographics
NPI:1720429525
Name:DIBERARDINO, NICOLE LYNN (OTR)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:DIBERARDINO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:RIVARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9492 BIRCH RUN RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48746-9781
Mailing Address - Country:US
Mailing Address - Phone:989-295-7906
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5185
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006488225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist