Provider Demographics
NPI:1982904736
Name:MONETTE, NICOLE RENE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:MONETTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENE
Other - Last Name:BLAESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:1261 S LAPEER RD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1419
Practice Address - Country:US
Practice Address - Phone:248-690-8030
Practice Address - Fax:248-690-8029
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F39531OtherBCBSM
MIP42630012Medicare PIN