Provider Demographics
NPI:1851879340
Name:RAIA, NICOLE MARIE LOUISE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE LOUISE
Last Name:RAIA
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 1:1704 MAPLE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3134
Mailing Address - Country:US
Mailing Address - Phone:630-933-1500
Mailing Address - Fax:224-271-5556
Practice Address - Street 1:1704 MAPLE AVE STE 110
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3134
Practice Address - Country:US
Practice Address - Phone:630-933-1500
Practice Address - Fax:224-271-5556
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018028503225100000X
IL070026028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist