Healthcare Provider Details

I. General information

NPI: 1659680650
Provider Name (Legal Business Name): TERRY MICELLI PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 09/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 STATE HIGHWAY 68
OGDENSBURG NY
13669-4403
US

IV. Provider business mailing address

8101 STATE HIGHWAY 68
OGDENSBURG NY
13669-4403
US

V. Phone/Fax

Practice location:
  • Phone: 315-393-0730
  • Fax: 315-393-9170
Mailing address:
  • Phone: 315-393-0730
  • Fax: 315-393-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006133-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: