Provider Demographics
NPI:1720380967
Name:CICCONE, SANDRA M (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:CICCONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 W WOOD ST
Mailing Address - Street 2:
Mailing Address - City:LOWELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44436-1042
Mailing Address - Country:US
Mailing Address - Phone:330-536-6178
Mailing Address - Fax:
Practice Address - Street 1:721 BOARDMAN POLAND RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5107
Practice Address - Country:US
Practice Address - Phone:330-726-9671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-03600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist