Provider Demographics
NPI:1902157480
Name:DELAGE, NICOLE E (ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:DELAGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 RIVER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2152
Mailing Address - Country:US
Mailing Address - Phone:203-863-2003
Mailing Address - Fax:203-863-2025
Practice Address - Street 1:31 RIVER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2152
Practice Address - Country:US
Practice Address - Phone:203-863-2003
Practice Address - Fax:203-863-2025
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03778Medicare PIN
NYWZWYR1Medicare PIN