Provider Demographics
NPI:1366958779
Name:NICOLAUS, MARNIE (MOT, OTR/L)
Entity type:Individual
Prefix:MS
First Name:MARNIE
Middle Name:
Last Name:NICOLAUS
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16442 NELSON PARK DR APT 104
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-5875
Mailing Address - Country:US
Mailing Address - Phone:517-745-4942
Mailing Address - Fax:
Practice Address - Street 1:14055 TOWN LOOP BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6105
Practice Address - Country:US
Practice Address - Phone:407-857-6285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18838225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist