Provider Demographics
NPI:1164535662
Name:CICOTTE, CHRISTINE M (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:M
Last Name:CICOTTE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:M
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1155 WENTZVILLE PKWY
Mailing Address - Street 2:SUITE 123
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3476
Mailing Address - Country:US
Mailing Address - Phone:636-332-1313
Mailing Address - Fax:636-332-2929
Practice Address - Street 1:1155 WENTZVILLE PKWY
Practice Address - Street 2:SUITE 123
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3476
Practice Address - Country:US
Practice Address - Phone:636-332-1313
Practice Address - Fax:636-332-2929
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002000822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist