Provider Demographics
NPI:1861210981
Name:MOWERY, NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MOWERY
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 1:1100 SPRUCE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:KULPMONT
Mailing Address - State:PA
Mailing Address - Zip Code:17834-1239
Mailing Address - Country:US
Mailing Address - Phone:570-373-2112
Mailing Address - Fax:
Practice Address - Street 1:1100 SPRUCE ST STE 100
Practice Address - Street 2:
Practice Address - City:KULPMONT
Practice Address - State:PA
Practice Address - Zip Code:17834-1239
Practice Address - Country:US
Practice Address - Phone:570-373-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP005818224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant