Provider Demographics
NPI:1417308420
Name:NEWBERRY, NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NEWBERRY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1430 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4208
Mailing Address - Country:US
Mailing Address - Phone:801-308-8198
Mailing Address - Fax:
Practice Address - Street 1:1430 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4208
Practice Address - Country:US
Practice Address - Phone:801-308-8198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9808065-2401225100000X
MO2014026904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist