Provider Demographics
NPI:1356554240
Name:CICCHETTI, REBECCA LYNN (PT)
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:LYNN
Last Name:CICCHETTI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:MCVEIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5431 CANNA COURT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6690
Mailing Address - Country:US
Mailing Address - Phone:860-794-8153
Mailing Address - Fax:
Practice Address - Street 1:2568 S RIDGEWOOD
Practice Address - Street 2:SUITE 1
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141
Practice Address - Country:US
Practice Address - Phone:386-423-0100
Practice Address - Fax:386-428-8831
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist