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General NPI Number Information
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NPI Number | 1386043677
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Entity Type | Individual
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Provider Name | NICHOLAS MICHAEL LICAMELI PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 08/22/2014
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Last Update Date | 08/22/2014
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Provider Practice Location Address
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Address Line | 2 BRIGHTON RD
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City | CLIFTON
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State | NJ
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Zip | 07012-1663
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Country | US
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Telephone | 973-928-6969
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Fax | 973-928-6968
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Provider Business Mailing Address
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Address Line | 62 BEECH ST
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City | NUTLEY
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State | NJ
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Zip | 07110-2227
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Country | US
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Telephone | 973-661-5240
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 40QA01560900
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License Number State | NJ
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