Provider Demographics
NPI:1578541025
Name:FREDERICKS, NICOLE L (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:HOOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2880 US HIGHWAY 9
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VALATIE
Mailing Address - State:NY
Mailing Address - Zip Code:12184-5423
Mailing Address - Country:US
Mailing Address - Phone:518-758-6070
Mailing Address - Fax:518-758-6379
Practice Address - Street 1:2880 US HIGHWAY 9
Practice Address - Street 2:SUITE 1
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-5423
Practice Address - Country:US
Practice Address - Phone:518-758-6070
Practice Address - Fax:518-758-6379
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ47401Medicare ID - Type Unspecified