Healthcare Provider Details

I. General information

NPI: 1417164856
Provider Name (Legal Business Name): WALTER J. CIECKO JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N HARRISON ST STE 101
WILMINGTON DE
19806-3163
US

IV. Provider business mailing address

1301 N HARRISON ST STE 101
WILMINGTON DE
19806-3163
US

V. Phone/Fax

Practice location:
  • Phone: 302-429-0195
  • Fax: 302-777-1712
Mailing address:
  • Phone: 302-429-0195
  • Fax: 302-777-1712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberB10000167
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: