Provider Demographics
NPI:1851454128
Name:THEARD, NICOLETTE (PT)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:THEARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10758 WILKINS AVE
Mailing Address - Street 2:# 2
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5060
Mailing Address - Country:US
Mailing Address - Phone:310-470-7618
Mailing Address - Fax:310-273-1189
Practice Address - Street 1:900 WILSHIRE BLVD
Practice Address - Street 2:SUITE 315
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1872
Practice Address - Country:US
Practice Address - Phone:310-458-0261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty