Provider Demographics
NPI:1356698609
Name:FRIEDERICH, NICHOLE E (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:E
Last Name:FRIEDERICH
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 1:880 COLUMBIA CENTRE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236
Mailing Address - Country:US
Mailing Address - Phone:618-281-9699
Mailing Address - Fax:618-281-9698
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-5555
Practice Address - Fax:618-939-3424
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0702012868691OtherDPR ID#