Provider Demographics
NPI:1205106333
Name:TETREAULT, NICOLE CHRISTINE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:TETREAULT
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 1:234 S FIGUEROA ST
Mailing Address - Street 2:APT 1837
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3283 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3709
Practice Address - Country:US
Practice Address - Phone:310-845-9690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist