Provider Demographics
NPI:1982162368
Name:GORNICK, NICHOLAS VINCENT (PT, DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:VINCENT
Last Name:GORNICK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CHATHAM RD STE N
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:822 S SUMMIT
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181
Practice Address - Country:US
Practice Address - Phone:630-426-1474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.023705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist