Provider Demographics
NPI:1013941046
Name:REA, NICOLE JENNIFER (MPT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JENNIFER
Last Name:REA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1187 COAST VILLAGE RD
Mailing Address - Street 2:STE 8
Mailing Address - City:MONTECITO
Mailing Address - State:CA
Mailing Address - Zip Code:93108-2762
Mailing Address - Country:US
Mailing Address - Phone:805-565-5670
Mailing Address - Fax:805-565-5690
Practice Address - Street 1:1187 COAST VILLAGE RD
Practice Address - Street 2:STE 8
Practice Address - City:MONTECITO
Practice Address - State:CA
Practice Address - Zip Code:93108-2762
Practice Address - Country:US
Practice Address - Phone:805-565-5670
Practice Address - Fax:805-565-5690
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27082261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT27082OtherSTATE LICENSE NUMBER
CAWPT27082AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAPT27082OtherSTATE LICENSE NUMBER