Provider Demographics
NPI:1114454980
Name:NICHOLLS, GLADYS (PT)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4616 W HOWARD LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 N LAMAR BLVD
Practice Address - Street 2:STE E-103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-1073
Practice Address - Country:US
Practice Address - Phone:512-324-1875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1104982225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist