Provider Demographics
NPI:1982941373
Name:DATTILO, NICOLE B (DPT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:B
Last Name:DATTILO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:B
Other - Last Name:DIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1895 WALT WHITMAN RD.
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747
Mailing Address - Country:US
Mailing Address - Phone:631-577-3400
Mailing Address - Fax:361-577-3409
Practice Address - Street 1:1895 WALT WHITMAN RD.
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747
Practice Address - Country:US
Practice Address - Phone:631-577-3400
Practice Address - Fax:361-577-3409
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-06
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist