Provider Demographics
NPI:1992063481
Name:HUCKABY, NICHOLAS REYNARD (DPT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:REYNARD
Last Name:HUCKABY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2376 FERNBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-5215
Mailing Address - Country:US
Mailing Address - Phone:318-686-0601
Mailing Address - Fax:
Practice Address - Street 1:2575 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5812
Practice Address - Country:US
Practice Address - Phone:318-286-5445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist