Provider Demographics
NPI:1467861328
Name:GROSSNICKLE, NEVIN (CERTIFIED MASSAGE TH)
Entity type:Individual
Prefix:
First Name:NEVIN
Middle Name:
Last Name:GROSSNICKLE
Suffix:
Gender:M
Credentials:CERTIFIED MASSAGE TH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 WAMBOLD DR
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-9583
Mailing Address - Country:US
Mailing Address - Phone:715-693-6095
Mailing Address - Fax:
Practice Address - Street 1:319 4TH STREET, LL
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403
Practice Address - Country:US
Practice Address - Phone:715-693-6095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10444-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist