Provider Demographics
NPI:1639625601
Name:OBERHOLTZER, NICOLE L (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:OBERHOLTZER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:ELDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1162B GORGAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94129-1406
Mailing Address - Country:US
Mailing Address - Phone:415-561-6655
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW STE A
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8867
Practice Address - Country:US
Practice Address - Phone:616-855-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist