Healthcare Provider Details

I. General information

NPI: 1356902100
Provider Name (Legal Business Name): NICOLE WILKERSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 LADEAN CT STE E
SIMPSONVILLE SC
29680-7504
US

IV. Provider business mailing address

222 LADEAN CT STE E
SIMPSONVILLE SC
29680-7504
US

V. Phone/Fax

Practice location:
  • Phone: 645-587-5198
  • Fax:
Mailing address:
  • Phone: 864-558-7519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number.6669
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-89795
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: