Provider Demographics
NPI:1306032206
Name:TICZON, MARI JANE ACADEMIA (RPT)
Entity Type:Individual
Prefix:MISS
First Name:MARI JANE
Middle Name:ACADEMIA
Last Name:TICZON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 W COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3440
Mailing Address - Country:US
Mailing Address - Phone:954-739-4247
Mailing Address - Fax:954-332-4340
Practice Address - Street 1:11 PONTIAC AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-1629
Practice Address - Country:US
Practice Address - Phone:508-943-3889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist