Healthcare Provider Details

I. General information

NPI: 1043446180
Provider Name (Legal Business Name): JANICE C. CICCARELLI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 1ST ST STE 314
CLAREMONT CA
91711-4741
US

IV. Provider business mailing address

250 W 1ST ST STE 314
CLAREMONT CA
91711-4741
US

V. Phone/Fax

Practice location:
  • Phone: 909-482-1200
  • Fax:
Mailing address:
  • Phone: 909-482-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY16212
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY16212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: