Provider Demographics
NPI:1649399239
Name:NICKEL, GAYLA J (COTA)
Entity type:Individual
Prefix:
First Name:GAYLA
Middle Name:J
Last Name:NICKEL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2567 MARTHAS LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62612-8081
Mailing Address - Country:US
Mailing Address - Phone:217-862-0400
Mailing Address - Fax:
Practice Address - Street 1:3132 OLD JACKSONVILLE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7400
Practice Address - Country:US
Practice Address - Phone:217-862-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant