Provider Demographics
NPI:1568827657
Name:BLACK, NICHOLAS ANDREW (PTA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:BLACK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 TUCKER BROOK RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04849-5528
Mailing Address - Country:US
Mailing Address - Phone:207-763-2745
Mailing Address - Fax:
Practice Address - Street 1:167 TUCKER BROOK RD
Practice Address - Street 2:
Practice Address - City:LINCOLNVILLE
Practice Address - State:ME
Practice Address - Zip Code:04849-5528
Practice Address - Country:US
Practice Address - Phone:207-763-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4548225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant