Healthcare Provider Details

I. General information

NPI: 1114846631
Provider Name (Legal Business Name): SAGE V NICHELSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAGE LANDRY OTR/L

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 BRESLAY DR
MELBOURNE FL
32940-8442
US

IV. Provider business mailing address

1228 COASTAL MEADOW TRL
JACKSONVILLE FL
32218-3546
US

V. Phone/Fax

Practice location:
  • Phone: 207-212-0654
  • Fax:
Mailing address:
  • Phone: 207-212-0654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT24021
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT24021
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: