Provider Demographics
NPI:1467028845
Name:THELL, NICHOLAS HENRY (PT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:HENRY
Last Name:THELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:211 S BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:PROCTOR
Practice Address - State:MN
Practice Address - Zip Code:55810-2306
Practice Address - Country:US
Practice Address - Phone:218-576-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15333225100000X
MN11848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist