Provider Demographics
NPI:1144920919
Name:NIKITICH, BROOKE R (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:R
Last Name:NIKITICH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:R
Other - Last Name:SOUSIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:303 E ELM AVE
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9713
Mailing Address - Country:US
Mailing Address - Phone:518-944-1670
Mailing Address - Fax:
Practice Address - Street 1:3 INDUSTRIAL WAY E
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-3318
Practice Address - Country:US
Practice Address - Phone:732-544-1557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09150500224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant