Provider Demographics
NPI:1033383658
Name:CICCARONE, DAWN MICHELLE
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MICHELLE
Last Name:CICCARONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3323
Mailing Address - Country:US
Mailing Address - Phone:215-276-6000
Mailing Address - Fax:215-276-1329
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:ADMINISTRATION SUITE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6000
Practice Address - Fax:215-276-1329
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004125L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOC004125LOtherLICENSE NUMBER