Provider Demographics
NPI:1053121582
Name:NICHOLSON, ADAM (PT, DPT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5919 MARGO DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ANNE
Mailing Address - State:IL
Mailing Address - Zip Code:60964-4433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1490 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1830
Practice Address - Country:US
Practice Address - Phone:815-432-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.022059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist