Healthcare Provider Details

I. General information

NPI: 1033034624
Provider Name (Legal Business Name): NICOLE ALICIA PORTER OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 MAIN ST
GROTON MA
01450-1234
US

IV. Provider business mailing address

156 PLAIN RD
WESTFORD MA
01886-1839
US

V. Phone/Fax

Practice location:
  • Phone: 862-812-4944
  • Fax:
Mailing address:
  • Phone: 862-812-4944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTL14573
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: