Provider Demographics
NPI:1821514076
Name:SHIRES, NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHIRES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 ANNIS SQUAM HARBOUR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2553
Mailing Address - Country:US
Mailing Address - Phone:443-926-1952
Mailing Address - Fax:
Practice Address - Street 1:TWO WEST ROLLING CROSSROADS SUITE 100-102
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-6208
Practice Address - Country:US
Practice Address - Phone:410-747-1600
Practice Address - Fax:410-747-5202
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist