Provider Demographics
NPI:1861917577
Name:LEE, NICOLE MARIKO ELBY (PT,DPT,SCS,ATC,CSCS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIKO ELBY
Last Name:LEE
Suffix:
Gender:F
Credentials:PT,DPT,SCS,ATC,CSCS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIKO
Other - Last Name:ELBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT,DPT,SCS,ATC,CSCS
Mailing Address - Street 1:24255 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90263-3999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24255 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90263-3999
Practice Address - Country:US
Practice Address - Phone:310-506-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CAPT2921662251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer