Basic Information
| Provider Information | |||||||||
| NPI: | 1942384151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORITY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MERCALDO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MERCALDO | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31 OLD ROUTE 7 | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068041714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037400020 | ||||||||
| FaxNumber: | 2037750238 | ||||||||
| Practice Location | |||||||||
| Address1: | 130B GROVE ST | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067763668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603547605 | ||||||||
| FaxNumber: | 8603550089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8380 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 008351 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.