Provider Demographics
NPI:1619251253
Name:CICERELLO, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CICERELLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:THERIAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4401 N I-35
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-3432
Mailing Address - Country:US
Mailing Address - Phone:940-483-9020
Mailing Address - Fax:940-483-9021
Practice Address - Street 1:2301 OHIO DR
Practice Address - Street 2:SUITE 133
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-3927
Practice Address - Country:US
Practice Address - Phone:972-398-7881
Practice Address - Fax:972-398-7884
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1062669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist