Provider Demographics
NPI:1942401377
Name:BERUTICH, NICOLE MEREDITH (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MEREDITH
Last Name:BERUTICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WINTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-1234
Mailing Address - Country:US
Mailing Address - Phone:678-451-6327
Mailing Address - Fax:
Practice Address - Street 1:1121 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5425
Practice Address - Country:US
Practice Address - Phone:770-977-8111
Practice Address - Fax:770-565-5941
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist