Healthcare Provider Details

I. General information

NPI: 1033821558
Provider Name (Legal Business Name): PHILANA CICOLELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 BELMONT WAY
CHINO VALLEY AZ
86323-5795
US

IV. Provider business mailing address

656 BELMONT WAY
CHINO VALLEY AZ
86323-5795
US

V. Phone/Fax

Practice location:
  • Phone: 310-256-0491
  • Fax:
Mailing address:
  • Phone: 310-256-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: