Provider Demographics
NPI:1750118279
Name:CICERCHIA, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CICERCHIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-2254
Mailing Address - Country:US
Mailing Address - Phone:203-430-8803
Mailing Address - Fax:
Practice Address - Street 1:1111 STRATFORD AVE # UNITE319
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-6344
Practice Address - Country:US
Practice Address - Phone:475-473-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1906224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant