Provider Demographics
NPI:1205953031
Name:TIKONOFF, LAURA K (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:TIKONOFF
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ORCHARD ST
Mailing Address - Street 2:APT. 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-3038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:ACC 134
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist