Provider Demographics
NPI:1700949344
Name:NICOLAISEN, RACHAEL WILEY (DPT)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:WILEY
Last Name:NICOLAISEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:MICHELLE
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4330 KRAFT AVE
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2741
Mailing Address - Country:US
Mailing Address - Phone:541-521-8867
Mailing Address - Fax:
Practice Address - Street 1:6041 CADILLAC AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1702
Practice Address - Country:US
Practice Address - Phone:541-521-8867
Practice Address - Fax:541-521-8867
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28739OtherPT LICENSE
CAWPT28739AMedicare ID - Type Unspecified