Provider Demographics
NPI:1558885814
Name:CHILD, NICHOLAS AVERY
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:AVERY
Last Name:CHILD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 WALTER GRIFFIS RD
Mailing Address - Street 2:
Mailing Address - City:ODUM
Mailing Address - State:GA
Mailing Address - Zip Code:31555-8802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1251 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-7729
Practice Address - Country:US
Practice Address - Phone:912-559-2071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003613225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant