Provider Demographics
NPI:1760891428
Name:PERISA-CICCHILLO, LAUREN ELIZABETH (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:PERISA-CICCHILLO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1553 NILES CORTLAND RD SE STE 1
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3073
Mailing Address - Country:US
Mailing Address - Phone:330-372-2324
Mailing Address - Fax:330-372-2309
Practice Address - Street 1:1553 NILES CORTLAND RD SE STE 1
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3073
Practice Address - Country:US
Practice Address - Phone:330-372-2324
Practice Address - Fax:330-372-2309
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X, 2251N0400X, 2251H1200X, 2251S0007X
OHPT014947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109240Medicaid
OH0109240Medicaid