Provider Demographics
NPI:1205808094
Name:DICICCO, SARA H (PT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:H
Last Name:DICICCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 HARTFORD TPKE
Mailing Address - Street 2:SUITE U
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4852
Mailing Address - Country:US
Mailing Address - Phone:860-979-1611
Mailing Address - Fax:203-866-3014
Practice Address - Street 1:435 HARTFORD TPKE
Practice Address - Street 2:SUITE U
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4852
Practice Address - Country:US
Practice Address - Phone:860-870-8272
Practice Address - Fax:860-875-0804
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT006862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001021Medicare ID - Type Unspecified