Provider Demographics
NPI:1114382223
Name:LICCARDO, ALLISON MICHELE (DPT)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:MICHELE
Last Name:LICCARDO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 1ST ST
Mailing Address - Street 2:APT 4
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2460
Mailing Address - Country:US
Mailing Address - Phone:201-316-6650
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-441-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist