Provider Demographics
NPI:1538260518
Name:NICKELSON, SUSAN JEAN (OTRIL)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JEAN
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:OTRIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7804 CROFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-3204
Mailing Address - Country:US
Mailing Address - Phone:512-739-2370
Mailing Address - Fax:
Practice Address - Street 1:407 S OLD HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5310
Practice Address - Country:US
Practice Address - Phone:512-504-3035
Practice Address - Fax:512-504-9287
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT1320225X00000X
TX108876225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist