Provider Demographics
NPI:1386043677
Name:LICAMELI, NICHOLAS MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:LICAMELI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2227
Mailing Address - Country:US
Mailing Address - Phone:973-661-5240
Mailing Address - Fax:
Practice Address - Street 1:2 BRIGHTON RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1663
Practice Address - Country:US
Practice Address - Phone:973-928-6969
Practice Address - Fax:973-928-6968
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01560900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist