Healthcare Provider Details

I. General information

NPI: 1053226142
Provider Name (Legal Business Name): HEIDI ROSE NUCKOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 S HUDSON AVE
PASADENA CA
91101-3599
US

IV. Provider business mailing address

1945 STRATFORD AVE
SOUTH PASADENA CA
91030-4638
US

V. Phone/Fax

Practice location:
  • Phone: 626-396-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2256
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: