MEDICARE: DENISE E NICHOLS OT

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	056005205	IL

General Provider Information

NPI Number	:	1467515783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE E NICHOLS OT

Provider Business Mailing Address
First Line	:	4920 E STATE ST STE 4
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2262
Country	:	US
Telephone Number	:	815-637-1100
Fax Number	:	815-637-1200

Provider Business Practice Location Address
First Line	:	4920 E STATE ST STE 4
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2262
Country	:	US
Telephone Number	:	815-637-1100
Fax Number	:	815-637-1200

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/30/2023

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Directions to “ DENISE E NICHOLS OT” Practice Location

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