Healthcare Provider Details

I. General information

NPI: 1124222740
Provider Name (Legal Business Name): LEE A NICKEL MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 SAN JACINTO ST
HOUSTON TX
77004-2708
US

IV. Provider business mailing address

PO BOX 24809
HOUSTON TX
77229-4809
US

V. Phone/Fax

Practice location:
  • Phone: 713-652-3145
  • Fax: 713-652-3146
Mailing address:
  • Phone: 713-378-0667
  • Fax: 832-242-9515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1135762
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: