Provider Demographics
NPI:1225390305
Name:NICHOLS, DEIDRA (DPT)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:DEIDRA
Other - Middle Name:RAQUEL
Other - Last Name:GOSHERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:650 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-4900
Mailing Address - Country:US
Mailing Address - Phone:208-782-4744
Mailing Address - Fax:208-906-1554
Practice Address - Street 1:650 N STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-4900
Practice Address - Country:US
Practice Address - Phone:208-782-4744
Practice Address - Fax:208-906-1554
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT3043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1225390305Medicaid
ID20001259Medicare Oscar/Certification