Provider Demographics
NPI:1356474571
Name:VERSH, NICOLE A (PT, ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:VERSH
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:BEAUREGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, ATC
Mailing Address - Street 1:26471 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6378
Mailing Address - Country:US
Mailing Address - Phone:949-916-2601
Mailing Address - Fax:949-916-2302
Practice Address - Street 1:26471 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6378
Practice Address - Country:US
Practice Address - Phone:949-916-2601
Practice Address - Fax:949-916-2302
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT254192251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT25410AMedicare PIN