Provider Demographics
NPI:1871058297
Name:MAXIMOWICZ, NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MAXIMOWICZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 YOLANDA DR
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-8014
Mailing Address - Country:US
Mailing Address - Phone:570-262-5933
Mailing Address - Fax:
Practice Address - Street 1:1100 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:TX
Practice Address - Zip Code:79782-7978
Practice Address - Country:US
Practice Address - Phone:432-756-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC016142225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist