Healthcare Provider Details

I. General information

NPI: 1790504116
Provider Name (Legal Business Name): JUSTINE CICERALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUSTINE MACISAAC

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 STONELEIGH AVE STE 202
CARMEL NY
10512-2455
US

IV. Provider business mailing address

31 CAUSEWAY PARK
CARMEL NY
10512-4042
US

V. Phone/Fax

Practice location:
  • Phone: 845-706-2617
  • Fax:
Mailing address:
  • Phone: 845-706-2617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096437
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: