Healthcare Provider Details

I. General information

NPI: 1164960019
Provider Name (Legal Business Name): NICOLE HANLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 HAMPTON CIR
ROCHESTER HILLS MI
48307-4103
US

IV. Provider business mailing address

41100 HAMILTON DR
STERLING HEIGHTS MI
48313-3013
US

V. Phone/Fax

Practice location:
  • Phone: 248-853-7555
  • Fax: 248-853-7556
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501018094
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: