Provider Demographics
NPI:1326318296
Name:WOODARD, NICOLE MAE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MAE
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:310 E LAMOTTE ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:IL
Mailing Address - Zip Code:62451-1328
Mailing Address - Country:US
Mailing Address - Phone:618-586-4001
Mailing Address - Fax:
Practice Address - Street 1:567 N 5TH ST
Practice Address - Street 2:SS172
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1903
Practice Address - Country:US
Practice Address - Phone:812-237-9613
Practice Address - Fax:812-237-9612
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist