Provider Demographics
NPI:1982110706
Name:NICHOLS, SCOTT (DPT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 SIKES AVE
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5021
Mailing Address - Country:US
Mailing Address - Phone:573-471-5755
Mailing Address - Fax:573-471-5884
Practice Address - Street 1:1102 SIKES AVE
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5021
Practice Address - Country:US
Practice Address - Phone:573-471-5755
Practice Address - Fax:573-471-5884
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1184152255A2300X
MO118530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer