Provider Demographics
NPI:1679119036
Name:NICHOLS, CARLY ANNE (OTD OTR/L)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:ANNE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OTD OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 HIGHWAY 11 N STE C
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2401
Practice Address - Country:US
Practice Address - Phone:601-716-3196
Practice Address - Fax:601-974-9919
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT-4116225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist