Provider Demographics
NPI:1124210331
Name:FONTICIELLA, VIVIAN (PT)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:FONTICIELLA
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 1:1172 S DIXIE HWY
Mailing Address - Street 2:#530
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2918
Mailing Address - Country:US
Mailing Address - Phone:305-381-6224
Mailing Address - Fax:305-381-6294
Practice Address - Street 1:200 S BISCAYNE BLVD
Practice Address - Street 2:SUITE: 15-A
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-2310
Practice Address - Country:US
Practice Address - Phone:305-381-6224
Practice Address - Fax:305-381-6294
Is Sole Proprietor?:No
Enumeration Date:2007-08-11
Last Update Date:2007-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist