Healthcare Provider Details

I. General information

NPI: 1992185722
Provider Name (Legal Business Name): NICOLE MARIE VICINO OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2015
Last Update Date: 06/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9225 CARLTON HILLS BLVD 23
SANTEE CA
92071-2980
US

IV. Provider business mailing address

9225 CARLTON HILLS BLVD 23
SANTEE CA
92071-2980
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-0622
  • Fax:
Mailing address:
  • Phone: 619-692-0622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT14410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: