Provider Demographics
NPI:1013994235
Name:GHAREEB, NICOLA C (PT)
Entity Type:Individual
Prefix:MS
First Name:NICOLA
Middle Name:C
Last Name:GHAREEB
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLA
Other - Middle Name:
Other - Last Name:SNYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:
Practice Address - Street 1:175 MARCELL DRIVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341
Practice Address - Country:US
Practice Address - Phone:616-866-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION67270Medicare ID - Type Unspecified
MIP83089Medicare UPIN