Healthcare Provider Details

I. General information

NPI: 1578389870
Provider Name (Legal Business Name): MADISON CICALO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 N MAIN ST
KOKOMO IN
46901-4622
US

IV. Provider business mailing address

1012 W SYCAMORE ST
KOKOMO IN
46901-4325
US

V. Phone/Fax

Practice location:
  • Phone: 765-776-8933
  • Fax:
Mailing address:
  • Phone: 765-480-3707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3005214A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: