Provider Demographics
NPI:1124647466
Name:EMERSON, NICKLAUS ALAN (DPT)
Entity type:Individual
Prefix:
First Name:NICKLAUS
Middle Name:ALAN
Last Name:EMERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-2828
Mailing Address - Country:US
Mailing Address - Phone:406-897-2404
Mailing Address - Fax:406-897-2104
Practice Address - Street 1:906 9TH ST W # A
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-3806
Practice Address - Country:US
Practice Address - Phone:406-897-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-19164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist