Healthcare Provider Details

I. General information

NPI: 1316187248
Provider Name (Legal Business Name): NICOLE MARIE O'GARA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 03/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 4TH ST SW STE 103A
WAVERLY IA
50677-4389
US

IV. Provider business mailing address

1810 4TH ST SW STE 103A
WAVERLY IA
50677-4389
US

V. Phone/Fax

Practice location:
  • Phone: 319-352-6400
  • Fax: 319-352-4655
Mailing address:
  • Phone: 319-352-6400
  • Fax: 319-352-4655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number01468
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License Number01468
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number01468
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number01468
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License Number01468
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code224ZL0004X
TaxonomyLow Vision Occupational Therapy Assistant
License Number01468
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: