Provider Demographics
NPI:1285125922
Name:CERCEO, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CERCEO
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 1:3960 DENNISON AVE APT C4
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2736
Mailing Address - Country:US
Mailing Address - Phone:215-279-1543
Mailing Address - Fax:
Practice Address - Street 1:3960 DENNISON AVE APT C4
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-2736
Practice Address - Country:US
Practice Address - Phone:215-279-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG002363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist