Provider Demographics
NPI:1336511609
Name:RICCOBONI, MARCO (MSOT, OTR/L, ATP)
Entity Type:Individual
Prefix:MR
First Name:MARCO
Middle Name:
Last Name:RICCOBONI
Suffix:
Gender:M
Credentials:MSOT, OTR/L, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 MIDWAY CENTER
Mailing Address - Street 2:
Mailing Address - City:WOODWAY
Mailing Address - State:TX
Mailing Address - Zip Code:76712-1803
Mailing Address - Country:US
Mailing Address - Phone:254-773-1226
Mailing Address - Fax:
Practice Address - Street 1:172 MIDWAY CENTER
Practice Address - Street 2:
Practice Address - City:WOODWAY
Practice Address - State:TX
Practice Address - Zip Code:76712-7671
Practice Address - Country:US
Practice Address - Phone:254-773-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120002225X00000X
92965247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist