Provider Demographics
NPI:1467666198
Name:MICUCCI, CAROLYN MARIE
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:MARIE
Last Name:MICUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 TOME ST
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-3317
Mailing Address - Country:US
Mailing Address - Phone:610-586-3719
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1419
Practice Address - Country:US
Practice Address - Phone:610-525-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT001419E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist