Provider Demographics
NPI:1639299365
Name:DACQUISTO, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DACQUISTO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 EL CAMINO REAL
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-3811
Mailing Address - Country:US
Mailing Address - Phone:650-365-8350
Mailing Address - Fax:650-368-8353
Practice Address - Street 1:3351 EL CAMINO REAL
Practice Address - Street 2:SUITE 180
Practice Address - City:ATHERTON
Practice Address - State:CA
Practice Address - Zip Code:94027-3811
Practice Address - Country:US
Practice Address - Phone:650-365-8350
Practice Address - Fax:650-368-8353
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT286422251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28642OtherPT LICENSE