Provider Demographics
NPI:1629264841
Name:COSBY, NICOLE LAROUX (PHD, ATC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LAROUX
Last Name:COSBY
Suffix:
Gender:F
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 UNIVERSITY GDNS
Mailing Address - Street 2:#3
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-2508
Mailing Address - Country:US
Mailing Address - Phone:951-515-3054
Mailing Address - Fax:
Practice Address - Street 1:3900 LOMALAND DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2810
Practice Address - Country:US
Practice Address - Phone:951-515-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
226300000X
CA080320922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist