Provider Demographics
NPI:1265206593
Name:CIVIELLO, MICHAEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CIVIELLO
Suffix:
Gender:M
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 1:4264 BLACKSNAKE HILL RD NE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-7925
Mailing Address - Country:US
Mailing Address - Phone:330-401-3363
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-3204
Practice Address - Country:US
Practice Address - Phone:330-602-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist