Healthcare Provider Details

I. General information

NPI: 1447903901
Provider Name (Legal Business Name): ANGELA CICCHINELLI CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ELMWOOD PARK DR
DAYTON OH
45449-5402
US

IV. Provider business mailing address

100 ELMWOOD PARK DR
DAYTON OH
45449-5402
US

V. Phone/Fax

Practice location:
  • Phone: 937-384-0580
  • Fax: 937-384-0581
Mailing address:
  • Phone: 937-384-0580
  • Fax: 937-384-0581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.179658
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: