Provider Demographics
NPI:1871875138
Name:ROWOLD, NICOLE MARIE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:ROWOLD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:CATHELYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1929
Mailing Address - Country:US
Mailing Address - Phone:309-489-6077
Mailing Address - Fax:309-944-9259
Practice Address - Street 1:600 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1099
Practice Address - Country:US
Practice Address - Phone:309-944-9150
Practice Address - Fax:309-944-9259
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009450225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist