Healthcare Provider Details

I. General information

NPI: 1497273064
Provider Name (Legal Business Name): NICOLE GAGNET MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N LOOMIS ST
CHICAGO IL
60607-1147
US

IV. Provider business mailing address

7660 PEBBLE CREEK DRIVE
MAUMEE OH
43537
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-8487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.013639
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: