Provider Demographics
NPI:1942878269
Name:NICHOLSON, ROXANE (PT)
Entity type:Individual
Prefix:
First Name:ROXANE
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 VIENNA ST LOT 13
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-9160
Mailing Address - Country:US
Mailing Address - Phone:585-966-9166
Mailing Address - Fax:
Practice Address - Street 1:150 VANBUREN STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-331-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016024-01225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy