=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740951326
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE CIARAVINO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2021
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33111 PLYMOUTH RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-263-6250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 419885
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02241-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-294-4050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501020182
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------