Provider Demographics
NPI:1801569207
Name:GENTZSCH, NICHOLE DANIELLE (LPTA)
Entity type:Individual
Prefix:MISS
First Name:NICHOLE
Middle Name:DANIELLE
Last Name:GENTZSCH
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 CHOCTAW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOLTS SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:65043-1488
Mailing Address - Country:US
Mailing Address - Phone:573-353-2121
Mailing Address - Fax:
Practice Address - Street 1:1195 CHOCTAW RIDGE DR
Practice Address - Street 2:
Practice Address - City:HOLTS SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:65043-1488
Practice Address - Country:US
Practice Address - Phone:573-353-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038310225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant