Healthcare Provider Details

I. General information

NPI: 1134006067
Provider Name (Legal Business Name): NICOLE RENEE RUBASH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TRIANGLE SHOPPING CTR STE 270
LONGVIEW WA
98632-4684
US

IV. Provider business mailing address

142 BULLHEAD DR
CASTLE ROCK WA
98611-8074
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3750
  • Fax: 360-501-3755
Mailing address:
  • Phone: 360-431-4441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT61256790
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT61256790
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: