Healthcare Provider Details

I. General information

NPI: 1770636060
Provider Name (Legal Business Name): THOMAS NICOLLA CONSULTING SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28652 STATE HIGHWAY 23
STAMFORD NY
12167-1712
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 209
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 160-765-2804
  • Fax: 160-765-2804
Mailing address:
  • Phone: 518-786-1667
  • Fax: 518-786-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003627-1
License Number StateNY

VIII. Authorized Official

Name: THOMAS NICOLLA
Title or Position: OWNER
Credential:
Phone: 518-786-1667