MEDICARE: NICOLE ANN DAVAULT OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	110168	TX
2	225XP0200X	Pediatric Occupational Therapist

General Provider Information

NPI Number	:	1396879722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ANN DAVAULT OTR

Provider Business Mailing Address
First Line	:	413 ARBOR LAWN DR
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-4063
Country	:	US
Telephone Number	:	817-295-2258
Fax Number	:

Provider Business Practice Location Address
First Line	:	6800 TELEPHONE RD
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-2856
Country	:	US
Telephone Number	:	817-306-4200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/22/2008

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