Provider Demographics
NPI:1609321090
Name:NICKERSON, TODD (DPT)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6425
Mailing Address - Country:US
Mailing Address - Phone:575-439-9878
Mailing Address - Fax:575-439-9876
Practice Address - Street 1:1011 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6425
Practice Address - Country:US
Practice Address - Phone:575-439-9878
Practice Address - Fax:575-439-9876
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4875225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist