Provider Demographics
NPI:1790010353
Name:DACILLO, RYAN CATOLTOL
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CATOLTOL
Last Name:DACILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2854
Mailing Address - Country:US
Mailing Address - Phone:732-320-3184
Mailing Address - Fax:
Practice Address - Street 1:1108 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2854
Practice Address - Country:US
Practice Address - Phone:732-320-3184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006517225200000X
NY032480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant