Healthcare Provider Details

I. General information

NPI: 1033383658
Provider Name (Legal Business Name): DAWN MICHELLE CICCARONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W GODFREY AVE ADMINISTRATION SUITE
PHILADELPHIA PA
19141-3323
US

IV. Provider business mailing address

1200 W GODFREY AVE
PHILADELPHIA PA
19141-3323
US

V. Phone/Fax

Practice location:
  • Phone: 215-276-6000
  • Fax: 215-276-1329
Mailing address:
  • Phone: 215-276-6000
  • Fax: 215-276-1329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC004125L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: