Provider Demographics
NPI:1477854131
Name:NICHOLS, BETHANY (PTA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 NE SHADY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-2508
Mailing Address - Country:US
Mailing Address - Phone:817-447-0404
Mailing Address - Fax:
Practice Address - Street 1:208 NE SHADY OAKS DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-2508
Practice Address - Country:US
Practice Address - Phone:817-447-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2066252225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant