Provider Demographics
NPI:1790188654
Name:NICKLIS, LAURA (DPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:NICKLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:GALLANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:44 DALE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4315
Practice Address - Country:US
Practice Address - Phone:860-674-1713
Practice Address - Fax:860-674-1848
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist