Provider Demographics
NPI:1063538908
Name:NICHOLSON, CAROL W (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:W
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 E VAUGHN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4817
Mailing Address - Country:US
Mailing Address - Phone:570-288-5344
Mailing Address - Fax:570-283-2167
Practice Address - Street 1:RIVERSTREET MANOR
Practice Address - Street 2:440 NORTH MAIN STREET
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-825-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003123L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist