Healthcare Provider Details

I. General information

NPI: 1780105189
Provider Name (Legal Business Name): KIMBERLY RAE CICERO OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20800 WESTGATE MALL STE 500
CLEVELAND OH
44126-1362
US

IV. Provider business mailing address

20800 WESTGATE MALL STE 500
CLEVELAND OH
44126-1362
US

V. Phone/Fax

Practice location:
  • Phone: 440-333-1880
  • Fax: 440-333-1834
Mailing address:
  • Phone: 440-333-1880
  • Fax: 440-333-1834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT008706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: