Provider Demographics
NPI:1184989964
Name:NICKOLI, DEBRA RENAE (PT)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:RENAE
Last Name:NICKOLI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:RENAE
Other - Last Name:NICKOLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 E ONTARIO ST APT 4003
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4443
Mailing Address - Country:US
Mailing Address - Phone:614-668-6237
Mailing Address - Fax:
Practice Address - Street 1:401 E ONTARIO ST APT 4003
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4443
Practice Address - Country:US
Practice Address - Phone:614-668-6237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700183902251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics