Provider Demographics
NPI:1740385616
Name:KLUCKHOHN, NICOLE SANFACON (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SANFACON
Last Name:KLUCKHOHN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SANFACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 BROOKFIELD PKWY STE 500A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5795
Mailing Address - Country:US
Mailing Address - Phone:864-549-0017
Mailing Address - Fax:864-528-5701
Practice Address - Street 1:225 BALLYHOO CT
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-4914
Practice Address - Country:US
Practice Address - Phone:864-907-5324
Practice Address - Fax:833-615-4258
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1787Medicaid
SCQ338018293Medicare PIN
SCQ338018293Medicare PIN