Healthcare Provider Details

I. General information

NPI: 1831625466
Provider Name (Legal Business Name): RICHARD J CICCHETTI LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 CHICAGO AVE
OAK PARK IL
60302
US

IV. Provider business mailing address

5635 N MENARD AVE
CHICAGO IL
60646-6309
US

V. Phone/Fax

Practice location:
  • Phone: 773-251-8714
  • Fax:
Mailing address:
  • Phone: 773-251-8714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011229
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: