Provider Demographics
NPI:1639713548
Name:RIETVELD, NICHOLAS SCOTT (DPT)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:SCOTT
Last Name:RIETVELD
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 1:1041 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-1221
Mailing Address - Country:US
Mailing Address - Phone:941-258-0501
Mailing Address - Fax:
Practice Address - Street 1:900 TAMIAMI TRL UNIT 111
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-5513
Practice Address - Country:US
Practice Address - Phone:941-347-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35274225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist