MEDICARE: GRACE NICOLE WILMES MOT, OTR/L

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	225XH1200X	Hand Occupational Therapist	122045	IA

General Provider Information

NPI Number	:	1992488100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE NICOLE WILMES MOT, OTR/L

Provider Business Mailing Address
First Line	:	3409 SINGING HILLS BLVD
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-5109
Country	:	US
Telephone Number	:	712-202-0702
Fax Number	:

Provider Business Practice Location Address
First Line	:	3409 SINGING HILLS BLVD
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-5109
Country	:	US
Telephone Number	:	712-202-0702
Fax Number	:

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

Provider Enumeration Date	:	08/14/2023
Last Update Date	:	08/14/2023

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