Provider Demographics
NPI:1417700022
Name:SUMMERS, NICKLAS (DPT)
Entity Type:Individual
Prefix:
First Name:NICKLAS
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18169 MORGARTS BEACH RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-2623
Mailing Address - Country:US
Mailing Address - Phone:618-218-9535
Mailing Address - Fax:
Practice Address - Street 1:5818 HARBOUR VIEW BLVD STE 150
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3327
Practice Address - Country:US
Practice Address - Phone:747-215-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216289225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist