Healthcare Provider Details

I. General information

NPI: 1881183606
Provider Name (Legal Business Name): STEPHANIE CICALIS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

320 FELLSWAY W APT 3
MEDFORD MA
02155-2646
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23452
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: