Provider Demographics
NPI:1649479544
Name:NICKSIC, TAMARA A (PT)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:A
Last Name:NICKSIC
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 1:2203 WYNNEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-2828
Mailing Address - Country:US
Mailing Address - Phone:219-789-5865
Mailing Address - Fax:
Practice Address - Street 1:8259 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8878
Practice Address - Country:US
Practice Address - Phone:219-365-6560
Practice Address - Fax:219-365-6561
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002433A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05002433AOtherLPT