Provider Demographics
NPI:1043073331
Name:CACICEDO, NICHOLAS (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CACICEDO
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 1:25241 ELEMENTARY WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7883
Mailing Address - Country:US
Mailing Address - Phone:239-947-4184
Mailing Address - Fax:239-941-4171
Practice Address - Street 1:25241 ELEMENTARY WAY STE 200
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7883
Practice Address - Country:US
Practice Address - Phone:239-947-4184
Practice Address - Fax:239-941-4171
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT41293225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist