Provider Demographics
NPI:1487916920
Name:GERLACH, NICHOLAS J (PT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:GERLACH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 S WHIPPOORWILL RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3626
Mailing Address - Country:US
Mailing Address - Phone:316-214-6100
Mailing Address - Fax:
Practice Address - Street 1:9360 E CENTRAL AVE # S100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2560
Practice Address - Country:US
Practice Address - Phone:316-636-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist