Provider Demographics
NPI:1417620402
Name:DICRISCIO, VINCENT JAMES (PHD, ATC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JAMES
Last Name:DICRISCIO
Suffix:
Gender:M
Credentials:PHD, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9438 BELLHALL DR
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4772
Mailing Address - Country:US
Mailing Address - Phone:443-442-4073
Mailing Address - Fax:
Practice Address - Street 1:4701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2404
Practice Address - Country:US
Practice Address - Phone:410-532-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00008532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer