Provider Demographics
NPI:1124670211
Name:SHIVELY, NICOLE (DPT, PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9105 TIDBALL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-7618
Mailing Address - Country:US
Mailing Address - Phone:518-944-6582
Mailing Address - Fax:
Practice Address - Street 1:4347 W NORTHWEST HWY STE 180
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-3863
Practice Address - Country:US
Practice Address - Phone:214-654-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist