Healthcare Provider Details

I. General information

NPI: 1932306735
Provider Name (Legal Business Name): TERRENCE LICCIARDI III RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 STILES RD
SALEM NH
03079-2859
US

IV. Provider business mailing address

37 14TH AVE
HAVERHILL MA
01830-3232
US

V. Phone/Fax

Practice location:
  • Phone: 603-898-3129
  • Fax:
Mailing address:
  • Phone: 978-521-0998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number06481
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number06481
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: