Provider Demographics
NPI:1730238585
Name:LICCIARDELLO, MICHELLE G (PT, CERT MDT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:G
Last Name:LICCIARDELLO
Suffix:
Gender:F
Credentials:PT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 W UTICA ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3048
Mailing Address - Country:US
Mailing Address - Phone:315-342-2738
Mailing Address - Fax:315-342-2815
Practice Address - Street 1:90 W UTICA ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3048
Practice Address - Country:US
Practice Address - Phone:315-342-2738
Practice Address - Fax:315-342-2815
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0134981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4130726OtherMVP SELECT CARE
NY11353159OtherCAQH NUMBER
NYBB5786Medicare ID - Type UnspecifiedMEDICARE NUMBER