Provider Demographics
NPI:1396168399
Name:NICKERSON, JULIE SENECAL (MPT)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:SENECAL
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 PARK CREST DR
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1423
Mailing Address - Country:US
Mailing Address - Phone:704-661-3829
Mailing Address - Fax:
Practice Address - Street 1:12600 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3469
Practice Address - Country:US
Practice Address - Phone:262-387-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11889-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist