MEDICARE: JULIANNE TICE DPT

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	225100000X	Physical Therapist	PT023601	PA

General Provider Information

NPI Number	:	1790199123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIANNE TICE DPT

Provider Business Mailing Address
First Line	:	1326 N 4TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19122-4414
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 W OREGON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3700
Country	:	US
Telephone Number	:	215-467-1800
Fax Number	:

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

Provider Enumeration Date	:	06/13/2014
Last Update Date	:	06/13/2014

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