Provider Demographics
NPI:1225857246
Name:CULICERTO, EMILY DAWN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:DAWN
Last Name:CULICERTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:DAWN
Other - Last Name:LILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 HUNTERS XING
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-8331
Mailing Address - Country:US
Mailing Address - Phone:304-860-8794
Mailing Address - Fax:
Practice Address - Street 1:1631 RITTER DR
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9264
Practice Address - Country:US
Practice Address - Phone:305-130-4763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002699225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant