| Doctor Name: | KRISTIN ANN DI VICO |
| NPI Number: | 1700076866 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MSPT |
| License Number: | PT 014 318-1 |
| Business Practice Address: | 3400 N Shelley St Mohegan Lake, NY - 105471441 |
| Business Phone Number: | 9149623458 |
| Business Fax Number: | |
| Mailing Address: | 3400 N Shelley St, MOHEGAN LAKE |
| State: | NY |
| Postal Code: | 105471441 |
| Phone Number: | 9149623458 |
| Fax Number: | |
| NPI Enumeration Date: | 07/25/2007 |
| NPI Last Update Date: | 07/25/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2251P0200X |
| License Number: | PT 014 318-1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | Pediatrics |
| Taxonomy Definition: | |