Provider Demographics
NPI:1497304414
Name:CRUSE, NICHOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:CRUSE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 LA CRESCENT ST APT 141
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-4007
Mailing Address - Country:US
Mailing Address - Phone:608-774-5703
Mailing Address - Fax:
Practice Address - Street 1:1505 BUTTS AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-2405
Practice Address - Country:US
Practice Address - Phone:608-372-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14582-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist