Provider Demographics
NPI:1902076649
Name:FABRE, NICOLE MARIE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:FABRE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SENECA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4171 HWY 1 S. STE 10
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767
Mailing Address - Country:US
Mailing Address - Phone:225-416-0333
Mailing Address - Fax:225-416-0332
Practice Address - Street 1:4171 HWY 1 S. STE 10
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767
Practice Address - Country:US
Practice Address - Phone:225-416-0333
Practice Address - Fax:225-416-0332
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721512274OtherTAX ID
LA1693081Medicaid
LA2520423Medicaid
LA721342481OtherTAX ID