Provider Demographics
NPI:1508477340
Name:NICHOLSON, BRIAN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:NICHOLSON
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 1:529 SW GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6614
Mailing Address - Country:US
Mailing Address - Phone:727-992-1978
Mailing Address - Fax:
Practice Address - Street 1:8100 NW 27TH BLVD APT D116
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-8613
Practice Address - Country:US
Practice Address - Phone:352-792-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist