Provider Demographics
NPI:1245484054
Name:SICCARDI, KIM (MT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SICCARDI
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FARMERS LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-1712
Mailing Address - Country:US
Mailing Address - Phone:845-469-7960
Mailing Address - Fax:
Practice Address - Street 1:23 FARMERS LN
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-1712
Practice Address - Country:US
Practice Address - Phone:845-469-7960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ145012-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist