Healthcare Provider Details

I. General information

NPI: 1861940322
Provider Name (Legal Business Name): ANTHONY CIPOLETTI OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 JACQUELYN LN
DALLAS PA
18612
US

IV. Provider business mailing address

5 JACQUELYN LN
DALLAS PA
18612-9107
US

V. Phone/Fax

Practice location:
  • Phone: 631-223-6713
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number020190
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC007780
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: