Healthcare Provider Details

I. General information

NPI: 1932405727
Provider Name (Legal Business Name): SAMANTHA CICCARELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 BROADWAY ST
BUFFALO NY
14212-1501
US

IV. Provider business mailing address

1526 WALDEN AVE STE 400
CHEEKTOWAGA NY
14225-4985
US

V. Phone/Fax

Practice location:
  • Phone: 716-896-7422
  • Fax: 716-896-7717
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005542
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: