Provider Demographics
NPI:1730646779
Name:DELA CRUZ, NICOLE BERGESCH (PT)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:BERGESCH
Last Name:DELA CRUZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BERGESCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2340 CAROL VIEW DR APT E109
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-2039
Mailing Address - Country:US
Mailing Address - Phone:310-740-1003
Mailing Address - Fax:
Practice Address - Street 1:3633 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4568
Practice Address - Country:US
Practice Address - Phone:760-729-7298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist