Provider Demographics
NPI:1295860922
Name:NICODEMUS, BETTY H (RPT)
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:H
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 MORGAN AVE SW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-4616
Mailing Address - Country:US
Mailing Address - Phone:256-775-1731
Mailing Address - Fax:
Practice Address - Street 1:245 CAHABA VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-2216
Practice Address - Country:US
Practice Address - Phone:205-942-6820
Practice Address - Fax:205-942-5627
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-36221OtherBLUE CROSS BLUE SHIELD