Healthcare Provider Details

I. General information

NPI: 1982077228
Provider Name (Legal Business Name): NELLA CICIULLA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 US HIGHWAY 1
ROCKLEDGE FL
32955-2712
US

IV. Provider business mailing address

1276 CYPRESS TRACE DR
MELBOURNE FL
32940-1620
US

V. Phone/Fax

Practice location:
  • Phone: 321-405-2751
  • Fax:
Mailing address:
  • Phone: 321-506-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH16147
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: