Provider Demographics
NPI:1689616179
Name:CUCINOTTA, KELLY M (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CUCINOTTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4169
Practice Address - Country:US
Practice Address - Phone:302-894-1800
Practice Address - Fax:302-894-1811
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001378225100000X
PAPT006924L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0454043000OtherAMERIHEALTH
DE100037586Medicaid
DE006839F68Medicare ID - Type Unspecified
DE100037586Medicaid
DE021003A78Medicare PIN