Healthcare Provider Details

I. General information

NPI: 1033241625
Provider Name (Legal Business Name): DONNA MARIE CICCONE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S FULLERTON AVE
MONTCLAIR NJ
07042-6304
US

IV. Provider business mailing address

11 S FULLERTON AVE
MONTCLAIR NJ
07042-6304
US

V. Phone/Fax

Practice location:
  • Phone: 973-744-8400
  • Fax: 973-284-1195
Mailing address:
  • Phone: 973-744-8400
  • Fax: 973-284-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04532400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: