Provider Demographics
NPI:1386833481
Name:NICHOLSON, LORI CARROLL (PT)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:CARROLL
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 ASHLEY AVENUE
Mailing Address - Street 2:SUITE C102, PO BOX 250977
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:843-792-6366
Mailing Address - Fax:843-792-8665
Practice Address - Street 1:158 ASHLEY AVENUE
Practice Address - Street 2:SUITE C102
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-792-6366
Practice Address - Fax:843-792-8665
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist