Provider Demographics
NPI:1699374074
Name:PERSICO, ASHLEIGH
Entity Type:Individual
Prefix:
First Name:ASHLEIGH
Middle Name:
Last Name:PERSICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3638
Mailing Address - Country:US
Mailing Address - Phone:203-584-1213
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-3638
Practice Address - Country:US
Practice Address - Phone:203-584-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1234562081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine