Provider Demographics
NPI:1518197987
Name:SIACOTOS, ANTHONY THOMAS (LMT)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:THOMAS
Last Name:SIACOTOS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-2214
Mailing Address - Country:US
Mailing Address - Phone:914-946-3334
Mailing Address - Fax:
Practice Address - Street 1:15 N BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2214
Practice Address - Country:US
Practice Address - Phone:914-946-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist