Provider Demographics
NPI:1235414616
Name:CICCONE, ROBERT J (LMT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:CICCONE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 ODONIEL LOOP W
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-2333
Mailing Address - Country:US
Mailing Address - Phone:908-420-4201
Mailing Address - Fax:
Practice Address - Street 1:7110 ODONIEL LOOP W
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-2333
Practice Address - Country:US
Practice Address - Phone:908-420-4201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist