Provider Demographics
NPI:1538420955
Name:SUMMERVILLE, CHRISTINA NICHOLE (PT)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:NICHOLE
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WORTHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-9391
Mailing Address - Country:US
Mailing Address - Phone:716-472-0652
Mailing Address - Fax:
Practice Address - Street 1:9055 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1965
Practice Address - Country:US
Practice Address - Phone:716-472-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01512722081P2900X
NY015127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine