Provider Demographics
NPI:1992282966
Name:FREDERICK, NIKKI (COTA/L)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:897 N SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-7791
Mailing Address - Country:US
Mailing Address - Phone:812-798-7736
Mailing Address - Fax:
Practice Address - Street 1:10799 ALLIANCE DR
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-8909
Practice Address - Country:US
Practice Address - Phone:812-221-9715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002491A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant