Basic Information
| Provider Information | |||||||||
| NPI: | 1295860922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICODEMUS | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 MORGAN AVE SW | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350554616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567751731 | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 CAHABA VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | PELHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351242216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059426820 | ||||||||
| FaxNumber: | 2059425627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH3235 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 515-36221 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |