Provider Demographics
NPI:1780123653
Name:NICKELSON, KOURTNEY (PTA)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:NICKELSON
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 1:4746 E HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:MOORELAND
Mailing Address - State:IN
Mailing Address - Zip Code:47360
Mailing Address - Country:US
Mailing Address - Phone:765-571-2501
Mailing Address - Fax:
Practice Address - Street 1:118 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2923
Practice Address - Country:US
Practice Address - Phone:317-573-1037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005451A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant