Provider Demographics
NPI:1356593222
Name:PAVOLDI, NICHOLAS DANIEL (SIP, LMT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:DANIEL
Last Name:PAVOLDI
Suffix:
Gender:M
Credentials:SIP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4038
Mailing Address - Country:US
Mailing Address - Phone:518-389-2200
Mailing Address - Fax:
Practice Address - Street 1:578 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4038
Practice Address - Country:US
Practice Address - Phone:518-389-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009737225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist