Healthcare Provider Details

I. General information

NPI: 1043703069
Provider Name (Legal Business Name): ANTONIO SICILIANO LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 MICHIGAN AVE STE 122
EAST LANSING MI
48823-4072
US

IV. Provider business mailing address

1151 MICHIGAN AVE STE 122
EAST LANSING MI
48823-4072
US

V. Phone/Fax

Practice location:
  • Phone: 269-350-3470
  • Fax:
Mailing address:
  • Phone: 269-350-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114044
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: