Healthcare Provider Details

I. General information

NPI: 1962540732
Provider Name (Legal Business Name): DAWNA L CICAK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 MAIN ST
BINGHAMTON NY
13905-2522
US

IV. Provider business mailing address

257 MAIN ST
BINGHAMTON NY
13905-2522
US

V. Phone/Fax

Practice location:
  • Phone: 607-692-8275
  • Fax:
Mailing address:
  • Phone: 607-692-8275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number082279
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: