Basic Information
| Provider Information | |||||||||
| NPI: | 1982688974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACALUSO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | SMYTH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SMYTH | ||||||||
| OtherFirstName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5718 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599035718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067560134 | ||||||||
| FaxNumber: | 4063092579 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 BAKER AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | WHITEFISH | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599372955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068625033 | ||||||||
| FaxNumber: | 4068624933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00009835 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PTP-PT-LIC-19225 | MT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.