Provider Demographics
NPI:1114010683
Name:BOBAY, NICOLE M (MPT, WCS, CIMT, CSCS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BOBAY
Suffix:
Gender:F
Credentials:MPT, WCS, CIMT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772437
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2437
Mailing Address - Country:US
Mailing Address - Phone:317-575-7304
Mailing Address - Fax:317-575-7333
Practice Address - Street 1:10228 DUPONT CIRCLE DR E STE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1611
Practice Address - Country:US
Practice Address - Phone:260-222-7401
Practice Address - Fax:260-209-5956
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007516A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000208508OtherANTHEM
IN250440Medicare PIN