1053018168 NPI number — NICOLE STOTTS PT, DPT, GCS, CEEAA

Table of content: NICOLE STOTTS PT, DPT, GCS, CEEAA (NPI 1053018168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053018168 NPI number — NICOLE STOTTS PT, DPT, GCS, CEEAA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOTTS
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, GCS, CEEAA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053018168
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 UNIVERSITY PKWY
Provider Second Line Business Mailing Address:
DEPT OF PHYSICAL THERAPY
Provider Business Mailing Address City Name:
UNIVERSITY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-534-3147
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20201 S CRAWFORD AVE
Provider Second Line Business Practice Location Address:
INPATIENT THERAPY SERVICES
Provider Business Practice Location Address City Name:
OLYMPIA FIELDS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-747-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070018928 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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