Healthcare Provider Details

I. General information

NPI: 1891877528
Provider Name (Legal Business Name): KEITH D CICERONE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2048 OAK TREE RD
EDISON NJ
08820-2012
US

IV. Provider business mailing address

2048 OAK TREE RD
EDISON NJ
08820-2012
US

V. Phone/Fax

Practice location:
  • Phone: 732-906-2645
  • Fax: 732-906-9241
Mailing address:
  • Phone: 732-906-2645
  • Fax: 732-906-9241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number35SI00213000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: