Provider Demographics
NPI:1699289447
Name:MCCLAIN, NICOLE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:JANKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:148 SAULS ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2677
Mailing Address - Country:US
Mailing Address - Phone:843-374-0185
Mailing Address - Fax:843-374-0189
Practice Address - Street 1:108 BARRINGTON TOWN SQUARE DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-7792
Practice Address - Country:US
Practice Address - Phone:330-562-1655
Practice Address - Fax:330-562-1653
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8882225100000X
OHPT018944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist