Provider Demographics
NPI:1528360849
Name:MEAD, NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MEAD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LINDHOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:44191 PLYMOUTH OAKS BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6530
Practice Address - Country:US
Practice Address - Phone:734-259-7102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI62110059Medicare PIN
MIN69750014Medicare PIN