Healthcare Provider Details

I. General information

NPI: 1326790890
Provider Name (Legal Business Name): CARA CICALO MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 THEIS LN
BLAUVELT NY
10913-1004
US

IV. Provider business mailing address

11 THEIS LN
BLAUVELT NY
10913-1004
US

V. Phone/Fax

Practice location:
  • Phone: 914-843-5827
  • Fax:
Mailing address:
  • Phone: 914-843-5827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number010786
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: