Provider Demographics
NPI:1285631051
Name:PESKIN, NICOLE L (PT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:PESKIN
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 1:3000 CENTER GREEN DR
Mailing Address - Street 2:110
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2364
Mailing Address - Country:US
Mailing Address - Phone:303-601-6666
Mailing Address - Fax:303-447-3390
Practice Address - Street 1:3000 CENTER GREEN DR
Practice Address - Street 2:110
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2364
Practice Address - Country:US
Practice Address - Phone:303-601-6666
Practice Address - Fax:303-447-3390
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4817OtherPHYSICAL THERAPIST LICENS
R5953Medicare ID - Type Unspecified