Healthcare Provider Details

I. General information

NPI: 1053169524
Provider Name (Legal Business Name): LAUREN CICCARELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1099
US

IV. Provider business mailing address

135 ROBBINS ST
WALTHAM MA
02453-5104
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10002200
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: