Provider Demographics
NPI:1487137220
Name:SANDERS, NICOLE RAE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RAE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RAE
Other - Last Name:LAVIGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2927 S FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6498
Mailing Address - Country:US
Mailing Address - Phone:608-819-6394
Mailing Address - Fax:
Practice Address - Street 1:2927 S FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711
Practice Address - Country:US
Practice Address - Phone:608-816-6394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5534-27226000000X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist Assistant