Healthcare Provider Details

I. General information

NPI: 1760891428
Provider Name (Legal Business Name): LAUREN ELIZABETH PERISA-CICCHILLO PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1553 NILES CORTLAND RD SE STE 1
WARREN OH
44484-3073
US

IV. Provider business mailing address

1553 NILES CORTLAND RD SE STE 1
WARREN OH
44484-3073
US

V. Phone/Fax

Practice location:
  • Phone: 330-372-2324
  • Fax: 330-372-2309
Mailing address:
  • Phone: 330-372-2324
  • Fax: 330-372-2309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT014947
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: