Healthcare Provider Details

I. General information

NPI: 1679025662
Provider Name (Legal Business Name): AMANDA CICARELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2928 W 36TH ST
BROOKLYN NY
11224-1410
US

IV. Provider business mailing address

2928 W 36TH ST
BROOKLYN NY
11224-1410
US

V. Phone/Fax

Practice location:
  • Phone: 718-372-3300
  • Fax: 718-372-1314
Mailing address:
  • Phone: 718-372-3300
  • Fax: 718-372-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number060491
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: