Provider Demographics
NPI:1871240671
Name:O'DOHERTY, NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:O'DOHERTY
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 1:11 BIRCH HILL RD STE APT
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11560-1820
Mailing Address - Country:US
Mailing Address - Phone:516-801-6020
Mailing Address - Fax:
Practice Address - Street 1:11 BIRCH HILL RD STE APT
Practice Address - Street 2:
Practice Address - City:LOCUST VALLEY
Practice Address - State:NY
Practice Address - Zip Code:11560-1820
Practice Address - Country:US
Practice Address - Phone:516-801-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist