Provider Demographics
NPI:1164801387
Name:CICINELLI, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CICINELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HEMBREE PARK DR STE K
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-3867
Mailing Address - Country:US
Mailing Address - Phone:470-632-3775
Mailing Address - Fax:
Practice Address - Street 1:105 HEMBREE PARK DR STE K
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3867
Practice Address - Country:US
Practice Address - Phone:470-632-3775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2022-06-13
Deactivation Date:2022-05-06
Deactivation Code:
Reactivation Date:2022-06-03
Provider Licenses
StateLicense IDTaxonomies
CO0013255225100000X
GA012818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0013255OtherDORA