Provider Demographics
NPI:1396404539
Name:TUCCILLO, MITSUKO (LMT)
Entity Type:Individual
Prefix:
First Name:MITSUKO
Middle Name:
Last Name:TUCCILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MITSUKO
Other - Middle Name:
Other - Last Name:OHIRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 OVERLOOK DR STE 14
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-2875
Practice Address - Country:US
Practice Address - Phone:603-672-0272
Practice Address - Fax:603-672-0270
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7102225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty