Healthcare Provider Details

I. General information

NPI: 1275912511
Provider Name (Legal Business Name): NIKKI SOULEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E HAVENS AVE
MITCHELL SD
57301-7284
US

IV. Provider business mailing address

200 E HAVENS AVE
MITCHELL SD
57301-7284
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-6370
  • Fax: 605-995-6374
Mailing address:
  • Phone: 605-995-6370
  • Fax: 605-995-6374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0951
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number0951
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: