Provider Demographics
NPI:1982753091
Name:IACONO, DEBRA M (PT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:M
Last Name:IACONO
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:PO BOX 896239
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6239
Mailing Address - Country:US
Mailing Address - Phone:803-926-6810
Mailing Address - Fax:803-926-6811
Practice Address - Street 1:3799 12TH STREET EXT STE 100
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3750
Practice Address - Country:US
Practice Address - Phone:803-926-6810
Practice Address - Fax:803-926-6811
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1915OtherLICENSE #
SC570991893OtherEIN