Provider Demographics
NPI:1568831949
Name:NICHOLAS, DAISY
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 GOLFVIEW DR APT 104
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3801
Mailing Address - Country:US
Mailing Address - Phone:586-822-0798
Mailing Address - Fax:248-823-5910
Practice Address - Street 1:30551 STEPHENSON HWY STE B
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071
Practice Address - Country:US
Practice Address - Phone:248-556-5008
Practice Address - Fax:248-951-8924
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist