Healthcare Provider Details

I. General information

NPI: 1790962678
Provider Name (Legal Business Name): JOHN PAUL FICUCELLO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51-55 NORTH ROUTE 9W
WEST HAVERSTRAW NY
10993
US

IV. Provider business mailing address

14 JEANNES PL
TAPPAN NY
10983-2215
US

V. Phone/Fax

Practice location:
  • Phone: 845-786-4617
  • Fax: 845-786-4068
Mailing address:
  • Phone: 845-786-4617
  • Fax: 845-786-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number029580-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: