Provider Demographics
NPI:1184175549
Name:TICE, CLARICE (ATC)
Entity type:Individual
Prefix:
First Name:CLARICE
Middle Name:
Last Name:TICE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 ALDRICH RD
Mailing Address - Street 2:
Mailing Address - City:MILLERTON
Mailing Address - State:PA
Mailing Address - Zip Code:16936-9496
Mailing Address - Country:US
Mailing Address - Phone:570-404-6391
Mailing Address - Fax:
Practice Address - Street 1:116 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:PA
Practice Address - Zip Code:18810-1723
Practice Address - Country:US
Practice Address - Phone:570-888-0057
Practice Address - Fax:570-888-0058
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002738-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer