Provider Demographics
NPI:1902115926
Name:BOOKER, NICOLE MELISSA (OTR/L)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MELISSA
Last Name:BOOKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 W 93RD PL
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9401 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2221
Practice Address - Country:US
Practice Address - Phone:708-599-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-26
Last Update Date:2010-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007690225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist