Healthcare Provider Details

I. General information

NPI: 1588714810
Provider Name (Legal Business Name): DONALD S. CICCONE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BERGEN ST ADMC 12 1205
NEWARK NJ
07107-3000
US

IV. Provider business mailing address

30 BERGEN ST ADMC 12 1205
NEWARK NJ
07107-3000
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-0037
  • Fax: 973-972-9355
Mailing address:
  • Phone: 973-972-0037
  • Fax: 973-972-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00176400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: