Provider Demographics
NPI:1265543771
Name:BICKNELL, CONNIE T (PT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:T
Last Name:BICKNELL
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 1:190 MAIN ST
Mailing Address - Street 2:P.O. BOX 998
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-2324
Mailing Address - Country:US
Mailing Address - Phone:315-265-3990
Mailing Address - Fax:315-265-3993
Practice Address - Street 1:190 MAIN ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-2324
Practice Address - Country:US
Practice Address - Phone:315-265-3990
Practice Address - Fax:315-265-3993
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004765-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01466206Medicaid
NY55132BMedicare ID - Type Unspecified