Provider Demographics
NPI:1124415278
Name:BUCHWALD, NICOLE MARIE (LMT, PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BUCHWALD
Suffix:
Gender:F
Credentials:LMT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49357 PONTIAC TRL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-2068
Mailing Address - Country:US
Mailing Address - Phone:248-445-0788
Mailing Address - Fax:
Practice Address - Street 1:49357 PONTIAC TRL
Practice Address - Street 2:SUITE 104
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-2068
Practice Address - Country:US
Practice Address - Phone:248-445-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004244225200000X
MI7501001960225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant