Provider Demographics
NPI:1912314428
Name:CICCOTELLI, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:CICCOTELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-4408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008-1536
Practice Address - Country:US
Practice Address - Phone:732-541-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01555600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist