Provider Demographics
NPI:1417265984
Name:DOUGLAS, NICHOLE RAE (LMT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:RAE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-1331
Mailing Address - Country:US
Mailing Address - Phone:585-813-6993
Mailing Address - Fax:
Practice Address - Street 1:154 PEARL ST
Practice Address - Street 2:UP STAIRS
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2914
Practice Address - Country:US
Practice Address - Phone:585-813-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-18
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021525225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist