Provider Demographics
NPI:1912943796
Name:BAILKE, NICOLE C (MPT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:C
Last Name:BAILKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:C
Other - Last Name:MOROPOULOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:6700 N. PORT WASHINGTON RD.
Mailing Address - Street 2:C/O ST. FRANCIS CHILDREN'S CENTER
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3919
Mailing Address - Country:US
Mailing Address - Phone:414-351-8850
Mailing Address - Fax:414-351-8846
Practice Address - Street 1:6700 N. PORT WASHINGTON RD.
Practice Address - Street 2:ST. FRANCIS CHILDREN'S CENTER
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3919
Practice Address - Country:US
Practice Address - Phone:414-351-8850
Practice Address - Fax:414-351-8846
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9966-0242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40405800Medicaid