Healthcare Provider Details

I. General information

NPI: 1366823569
Provider Name (Legal Business Name): NICOLE LUCUS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE SIEBER

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 PARSONS AVE
COLUMBUS OH
43207-1933
US

IV. Provider business mailing address

2780 AIRPORT DR STE 100
COLUMBUS OH
43219-2289
US

V. Phone/Fax

Practice location:
  • Phone: 614-859-1967
  • Fax: 614-586-4252
Mailing address:
  • Phone: 614-859-1906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number015482
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: