Provider Demographics
NPI:1407373780
Name:DECICCO, THOMAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DECICCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CONTINENTAL DR
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:583 STATE ROUTE 32 STE 2U
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-5229
Practice Address - Country:US
Practice Address - Phone:845-928-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist