Provider Demographics
NPI:1700224243
Name:LEBARON, NICOLE JANE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JANE
Last Name:LEBARON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:JANE
Other - Last Name:QUINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10909 HANNAN RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1383
Mailing Address - Country:US
Mailing Address - Phone:734-893-1033
Mailing Address - Fax:
Practice Address - Street 1:10909 HANNAN RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1383
Practice Address - Country:US
Practice Address - Phone:734-893-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003682225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant