Provider Demographics
NPI:1326410622
Name:CLEARY, NICKOL MARIE (PT)
Entity Type:Individual
Prefix:
First Name:NICKOL
Middle Name:MARIE
Last Name:CLEARY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICKOL
Other - Middle Name:MARIE
Other - Last Name:NICKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1110 W SPRINGFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-6730
Mailing Address - Country:US
Mailing Address - Phone:814-558-7625
Mailing Address - Fax:
Practice Address - Street 1:785 E MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870
Practice Address - Country:US
Practice Address - Phone:814-238-3485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013551L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist