Basic Information
Provider Information
NPI: 1003141110
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NICHOLAS
FirstName: CARRIE
MiddleName: MARIE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: PAVLOCK
OtherFirstName: CARRIE
OtherMiddleName: MARIE
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: DPT
OtherLastNameType: 1
Mailing Information
Address1: 3399 WINTON RD S
Address2:  
City: ROCHESTER
State: NY
PostalCode: 146233057
CountryCode: US
TelephoneNumber: 5853346000
FaxNumber: 5853342852
Practice Location
Address1: 3399 WINTON RD S
Address2:  
City: ROCHESTER
State: NY
PostalCode: 146233057
CountryCode: US
TelephoneNumber: 5853346000
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/07/2009
LastUpdateDate: 02/18/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X0319291NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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