Provider Demographics
NPI:1841545951
Name:RACICH, NICHOLAS TYLER (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:TYLER
Last Name:RACICH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E MERCER AVE
Mailing Address - Street 2:APARTMENT 1A
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4743
Mailing Address - Country:US
Mailing Address - Phone:215-870-5166
Mailing Address - Fax:
Practice Address - Street 1:11 E MERCER AVE
Practice Address - Street 2:APARTMENT 1A
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4743
Practice Address - Country:US
Practice Address - Phone:215-870-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist