Provider Demographics
NPI:1265599252
Name:RICCIONE, COLEEN R (PT)
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:R
Last Name:RICCIONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WEST WAYNE PLAZA 1900 ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502
Mailing Address - Country:US
Mailing Address - Phone:315-986-4655
Mailing Address - Fax:315-986-5901
Practice Address - Street 1:WEST WAYNE PLAZA 1900 ROUTE 31
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502
Practice Address - Country:US
Practice Address - Phone:315-986-4655
Practice Address - Fax:315-986-5901
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01684335Medicaid
NY008672OtherWORKERS COMP
NY008672OtherWORKERS COMP