Healthcare Provider Details

I. General information

NPI: 1023561321
Provider Name (Legal Business Name): MELISSA CICCARELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 N RICHMOND AVE
MASSAPEQUA NY
11758-3230
US

IV. Provider business mailing address

5500 SUNRISE HIGHWAY UNIT 50 #1015
MASSAPEQUA NY
11758-3230
US

V. Phone/Fax

Practice location:
  • Phone: 516-652-7625
  • Fax:
Mailing address:
  • Phone: 516-652-7625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR083242
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number083242
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: