Provider Demographics
NPI:1811595234
Name:DICARLO, MARIO VINCENT (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:VINCENT
Last Name:DICARLO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 W RITTENHOUSE ST APT B120
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4316
Mailing Address - Country:US
Mailing Address - Phone:610-908-9775
Mailing Address - Fax:
Practice Address - Street 1:3485 DAVISVILLE RD
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-4220
Practice Address - Country:US
Practice Address - Phone:215-830-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE012508225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant