Provider Demographics
NPI:1104160993
Name:CICCARELLI, MICHELLE LYNNE (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNNE
Last Name:CICCARELLI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 AMITY RD
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3058
Mailing Address - Country:US
Mailing Address - Phone:203-668-6702
Mailing Address - Fax:
Practice Address - Street 1:6448 MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-2075
Practice Address - Country:US
Practice Address - Phone:203-220-2768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002090225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist