Healthcare Provider Details

I. General information

NPI: 1962164061
Provider Name (Legal Business Name): LILIANA CICOLELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 WESTCHESTER AVE STE N-230
WHITE PLAINS NY
10604-3522
US

IV. Provider business mailing address

2141 RYDER ST
BROOKLYN NY
11234-5003
US

V. Phone/Fax

Practice location:
  • Phone: 212-564-2350
  • Fax:
Mailing address:
  • Phone: 718-866-7764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: