Provider Demographics
NPI:1336210681
Name:DELISIO, NICHOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:DELISIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:BRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:9093 RIDGEFIELD DR
Mailing Address - Street 2:S 201
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-6712
Mailing Address - Country:US
Mailing Address - Phone:301-696-5595
Mailing Address - Fax:301-696-0842
Practice Address - Street 1:9135 PISCATAWAY RD
Practice Address - Street 2:SUITE 305
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2549
Practice Address - Country:US
Practice Address - Phone:301-877-2323
Practice Address - Fax:301-877-2366
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD427MN041Medicare ID - Type Unspecified