Provider Demographics
NPI:1487160453
Name:HENTNICK, NICOLE MAE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAE
Last Name:HENTNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BELMONT ST.
Mailing Address - Street 2:PHYSICAL THERAPY
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 BELMONT STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-334-6521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23307225100000X
CT11579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist