Healthcare Provider Details

I. General information

NPI: 1841976727
Provider Name (Legal Business Name): NICHOLAS NOBLITT PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9437 OLIVE BLVD
OLIVETTE MO
63132
US

IV. Provider business mailing address

3005 SIDNEY ST. #A
ST. LOUIS MO
63104
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2023024470
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: