MEDICARE: LISA MARIE CICCONE LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor	095647	NY

General Provider Information

NPI Number	:	1548784762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE CICCONE LMSW

Provider Business Mailing Address
First Line	:	PO BOX 193
Second Line	:
City	:	ESOPUS
State	:	NY
Zip	:	12429-0193
Country	:	US
Telephone Number	:	18455943162
Fax Number	:

Provider Business Practice Location Address
First Line	:	319 BROADWAY
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-5501
Country	:	US
Telephone Number	:	845-339-8707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2017
Last Update Date	:	07/30/2017

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