Healthcare Provider Details

I. General information

NPI: 1720380967
Provider Name (Legal Business Name): SANDRA M CICCONE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 BOARDMAN POLAND RD
BOARDMAN OH
44512-5107
US

IV. Provider business mailing address

426 W WOOD ST
LOWELLVILLE OH
44436-1042
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-9671
  • Fax:
Mailing address:
  • Phone: 330-536-6178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-03600
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: