Provider Demographics
NPI:1700123049
Name:CICCARIELLO, CHRISTY KELLY (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:KELLY
Last Name:CICCARIELLO
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 FLORENCE RD
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-7600
Mailing Address - Country:US
Mailing Address - Phone:617-827-6291
Mailing Address - Fax:
Practice Address - Street 1:4 SAMOSET WAY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048
Practice Address - Country:US
Practice Address - Phone:508-208-8438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9921208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics