Provider Demographics
NPI:1164424842
Name:GERGICH, NICOLE LYNN (MPT, CLT-LANA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LYNN
Last Name:GERGICH
Suffix:
Gender:F
Credentials:MPT, CLT-LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 WOODMONT AVE
Mailing Address - Street 2:#1209
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-5361
Mailing Address - Country:US
Mailing Address - Phone:301-718-7338
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:BLDG 10, 4 WEST
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:301-295-6372
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012155L225100000X
NJ40QA00968000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist