Provider Demographics
NPI:1992213169
Name:NICHOLS, LEAH ELLEN (PT, DPT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ELLEN
Last Name:NICHOLS
Suffix:
Gender:F
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 1:4639 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1828
Mailing Address - Country:US
Mailing Address - Phone:773-360-5485
Mailing Address - Fax:
Practice Address - Street 1:4639 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639
Practice Address - Country:US
Practice Address - Phone:773-360-5485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023074225100000X
AK128786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist