Provider Demographics
NPI:1619118510
Name:CECCARELLI, DOMONIC STEPHEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:DOMONIC
Middle Name:STEPHEN
Last Name:CECCARELLI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13048 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-3919
Mailing Address - Country:US
Mailing Address - Phone:206-214-5787
Mailing Address - Fax:
Practice Address - Street 1:13048 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-3919
Practice Address - Country:US
Practice Address - Phone:206-214-5787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160041007225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant