Provider Demographics
NPI:1942715842
Name:BISSON, NICOLE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BISSON
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 SW SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3195
Mailing Address - Country:US
Mailing Address - Phone:541-312-2004
Mailing Address - Fax:
Practice Address - Street 1:1288 SW SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3195
Practice Address - Country:US
Practice Address - Phone:541-312-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62537225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist