=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215320213
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE DEARTH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2015
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 E COURT ST
-----------------------------------------------------
City | SIDNEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45365-3021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-498-1654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 E COURT ST
-----------------------------------------------------
City | SIDNEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45365-3021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 7728
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------