Basic Information
| Provider Information | |||||||||
| NPI: | 1053478586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CERICOLA | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 52ND ST | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113773250 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 PELHAM PKWY S | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104611138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189183060 | ||||||||
| FaxNumber: | 7189184469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 010582 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.