Healthcare Provider Details

I. General information

NPI: 1336891183
Provider Name (Legal Business Name): THERESA NICHOLSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 N DECATUR RD UNIT 506
DECATUR GA
30033-5305
US

IV. Provider business mailing address

2107 N DECATUR RD UNIT 506
DECATUR GA
30033-5305
US

V. Phone/Fax

Practice location:
  • Phone: 470-831-4049
  • Fax: 770-626-0089
Mailing address:
  • Phone: 470-831-4049
  • Fax: 770-626-0089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT015743
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT015743
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: