MEDICARE: GAIL JEANNE LICCIARDELLO OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	NH202	NH

General Provider Information

NPI Number	:	1184936197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL JEANNE LICCIARDELLO OT

Provider Business Mailing Address
First Line	:	777 LAFAYETTE RD
Second Line	:
City	:	HAMPTON
State	:	NH
Zip	:	03842-1228
Country	:	US
Telephone Number	:	603-929-3032
Fax Number	:	603-926-6238

Provider Business Practice Location Address
First Line	:	777 LAFAYETTE RD
Second Line	:
City	:	HAMPTON
State	:	NH
Zip	:	03842-1228
Country	:	US
Telephone Number	:	603-929-3032
Fax Number	:	603-926-6238

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2010
Last Update Date	:	07/07/2010

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