Healthcare Provider Details

I. General information

NPI: 1659280295
Provider Name (Legal Business Name): NICOLE WALES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 GOLD STAR BLVD
WORCESTER MA
01606-2812
US

IV. Provider business mailing address

50 GOLD STAR BLVD
WORCESTER MA
01606-2812
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-9510
  • Fax: 508-853-1907
Mailing address:
  • Phone: 508-856-9510
  • Fax: 508-853-1907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL89655
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: