Healthcare Provider Details

I. General information

NPI: 1992176697
Provider Name (Legal Business Name): NICOLE CORRIVEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 8TH ST NE
WASHINGTON DC
20002-5227
US

IV. Provider business mailing address

405 8TH ST NE
WASHINGTON DC
20002-5227
US

V. Phone/Fax

Practice location:
  • Phone: 202-544-5439
  • Fax: 202-379-1797
Mailing address:
  • Phone: 202-544-5439
  • Fax: 202-379-1797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number07628
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT010001077
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: