Healthcare Provider Details

I. General information

NPI: 1780229039
Provider Name (Legal Business Name): NICK C DOUGLAS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7878 N 76TH ST
MILWAUKEE WI
53223-3914
US

IV. Provider business mailing address

7878 N 76TH ST
MILWAUKEE WI
53223-3914
US

V. Phone/Fax

Practice location:
  • Phone: 414-586-5760
  • Fax: 414-586-5780
Mailing address:
  • Phone: 414-586-5760
  • Fax: 414-586-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14830
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: