Provider Demographics
NPI:1093866444
Name:NICOSIA, MICHELE (BSPT, MSM)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:NICOSIA
Suffix:
Gender:F
Credentials:BSPT, MSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 MACKLIND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1440
Mailing Address - Country:US
Mailing Address - Phone:314-534-0200
Mailing Address - Fax:314-534-7996
Practice Address - Street 1:1129 MACKLIND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1440
Practice Address - Country:US
Practice Address - Phone:314-534-0200
Practice Address - Fax:314-534-7996
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist