Provider Demographics
NPI:1588108617
Name:DICROCE, THERESA VIOLA (PTA)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:VIOLA
Last Name:DICROCE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:VIOLA
Other - Last Name:MATTISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:ONE RAPP ROAD
Mailing Address - Street 2:ADVANCED THERAPY, P.L.L.C.
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:518-867-3061
Mailing Address - Fax:518-867-3066
Practice Address - Street 1:ONE RAPP ROAD
Practice Address - Street 2:ADVANCED THERAPY, P.L.L.C.
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203
Practice Address - Country:US
Practice Address - Phone:518-867-3061
Practice Address - Fax:518-867-3066
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001352-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant