Provider Demographics
NPI:1962122861
Name:CABALLO, NIKKI ROSE IYOG (OTR)
Entity type:Individual
Prefix:
First Name:NIKKI ROSE
Middle Name:IYOG
Last Name:CABALLO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 W 139TH ST APT 16
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-7509
Mailing Address - Country:US
Mailing Address - Phone:347-431-6275
Mailing Address - Fax:
Practice Address - Street 1:3418 NORTHERN BLVD STE 5-5
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2807
Practice Address - Country:US
Practice Address - Phone:212-529-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027051225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics