Provider Demographics
NPI:1033254156
Name:GRACILLA, ROCHELLE M (PT)
Entity Type:Individual
Prefix:MS
First Name:ROCHELLE
Middle Name:M
Last Name:GRACILLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1725
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-0725
Mailing Address - Country:US
Mailing Address - Phone:814-573-0314
Mailing Address - Fax:
Practice Address - Street 1:1455 BOLDE DR
Practice Address - Street 2:APT 1-D
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-2213
Practice Address - Country:US
Practice Address - Phone:814-573-0314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008728E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA020844Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER