Healthcare Provider Details

I. General information

NPI: 1194071159
Provider Name (Legal Business Name): GINA MARIE CICCHETTI B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 COMMUNITY LN
LIBERTY NY
12754-2851
US

IV. Provider business mailing address

20 COMMUNITY LN
LIBERTY NY
12754-2851
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-8770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: