Provider Demographics
NPI:1700064979
Name:NOLE, ROBERTA (MAPT, CPED)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:NOLE
Suffix:
Gender:F
Credentials:MAPT, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 TURNPIKE DR
Mailing Address - Street 2:UNIT 1
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1830
Mailing Address - Country:US
Mailing Address - Phone:203-758-8307
Mailing Address - Fax:203-758-8394
Practice Address - Street 1:80 TURNPIKE DR
Practice Address - Street 2:UNIT 1
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1830
Practice Address - Country:US
Practice Address - Phone:203-758-8307
Practice Address - Fax:203-758-8394
Is Sole Proprietor?:No
Enumeration Date:2008-02-09
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225000000X
CT003621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12DME0603CT01OtherANTHEM BLUE CROSS BLUE SHIELD
CT004137338Medicaid
CT5918940001Medicare NSC