Provider Demographics
NPI:1447564125
Name:MCLAIN, NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MCLAIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:NOREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3674 MIDDLEBURG LN
Mailing Address - Street 2:# 304
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4556
Mailing Address - Country:US
Mailing Address - Phone:321-960-6205
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7213
Practice Address - Country:US
Practice Address - Phone:321-255-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 25723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002420200Medicaid