Provider Demographics
NPI:1740235050
Name:NICHOLAS, LESLIE (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 ASHWOODY DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35633-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:416 N SEMINARY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-4657
Practice Address - Country:US
Practice Address - Phone:256-764-1442
Practice Address - Fax:256-764-1366
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51524378OtherBLUE CROSS ID#