Healthcare Provider Details

I. General information

NPI: 1588330666
Provider Name (Legal Business Name): EDWARD SCOTT NICKLAS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 BUNTON CREEK RD STE 302
KYLE TX
78640-5701
US

IV. Provider business mailing address

101 W LOUIS HENNA BLVD STE 300
AUSTIN TX
78728-1203
US

V. Phone/Fax

Practice location:
  • Phone: 512-492-3726
  • Fax: 512-492-3729
Mailing address:
  • Phone: 512-492-3743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1351611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: