Provider Demographics
NPI:1659680650
Name:MICELLI, TERRY (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:MICELLI
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 STATE HIGHWAY 68
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-4403
Mailing Address - Country:US
Mailing Address - Phone:315-393-0730
Mailing Address - Fax:315-393-9170
Practice Address - Street 1:8101 STATE HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-4403
Practice Address - Country:US
Practice Address - Phone:315-393-0730
Practice Address - Fax:315-393-9170
Is Sole Proprietor?:No
Enumeration Date:2010-09-26
Last Update Date:2010-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006133-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006133-1OtherPHYSICAL THERAPIST