Healthcare Provider Details

I. General information

NPI: 1609606565
Provider Name (Legal Business Name): KARA SUE CICCIARELLI PHD, NCSP, LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 N WILLOW LAKE CT
PEORIA IL
61614-8227
US

IV. Provider business mailing address

7317 N WILLOW LAKE CT
PEORIA IL
61614-8227
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-7373
  • Fax:
Mailing address:
  • Phone: 309-683-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071011250
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: