Provider Demographics
NPI:1962564831
Name:MCNICHOLAS, DEBRA ANNE (PTA)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANNE
Last Name:MCNICHOLAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5997 FEDERAL RD
Mailing Address - Street 2:
Mailing Address - City:CONESUS
Mailing Address - State:NY
Mailing Address - Zip Code:14435-9578
Mailing Address - Country:US
Mailing Address - Phone:585-346-2914
Mailing Address - Fax:
Practice Address - Street 1:11 MURRAY HILL DR
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510-1153
Practice Address - Country:US
Practice Address - Phone:585-243-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004097-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant