Provider Demographics
NPI:1689906422
Name:NICOLAYSEN, RICHARD BJORN (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BJORN
Last Name:NICOLAYSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 CLOCK TOWER COMMONS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4064
Mailing Address - Country:US
Mailing Address - Phone:845-278-4068
Mailing Address - Fax:
Practice Address - Street 1:614 CLOCK TOWER COMMONS
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4064
Practice Address - Country:US
Practice Address - Phone:845-278-4068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004718-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist