Provider Demographics
NPI:1821287319
Name:ICASIANO, ROY G (PT)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:G
Last Name:ICASIANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2788 STONEY CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5288
Mailing Address - Country:US
Mailing Address - Phone:970-240-0500
Mailing Address - Fax:
Practice Address - Street 1:2788 STONEY CREEK LN
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5288
Practice Address - Country:US
Practice Address - Phone:970-240-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL7247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist