Individual
NICOLE M IWANOWSKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTR/L, CLT
Contact information
Practice address
10222 74TH ST, SUITE 211, KENOSHA, WI 53142-6810
(262) 925-5020
(262) 925-5021
Mailing address
600 52ND ST, SUITE 240, KENOSHA, WI 53140-3423
(262) 925-5004
(262) 925-5001
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
4230026
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11781771
CAQH
WI
05
—
1295844603
—
WI
Enumeration date
08/30/2006
Last updated
10/19/2017
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