Provider Demographics
NPI:1376590349
Name:NICOLL, DENISE (PT)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:NICOLL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6339 E GREENWAY RD STE 102
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6524
Practice Address - Country:US
Practice Address - Phone:480-482-2842
Practice Address - Fax:480-222-1457
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011370225100000X
AZ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK 24168Medicare ID - Type UnspecifiedMEDICARE