Provider Demographics
NPI:1063179604
Name:NICHOLS, CAROLYN MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 WISEMAN BLVD
Mailing Address - Street 2:BLDG V, SUITE 502
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251
Mailing Address - Country:US
Mailing Address - Phone:210-775-6655
Mailing Address - Fax:210-761-7291
Practice Address - Street 1:3922 WISEMAN BLVD
Practice Address - Street 2:BLDG V, SUITE 502
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:210-775-6655
Practice Address - Fax:210-761-7291
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1384954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist