Healthcare Provider Details

I. General information

NPI: 1972064335
Provider Name (Legal Business Name): MARISA CICCONE LCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 N UNION ST
PAWTUCKET RI
02860-2915
US

IV. Provider business mailing address

31 N UNION ST
PAWTUCKET RI
02860-2915
US

V. Phone/Fax

Practice location:
  • Phone: 401-725-2520
  • Fax: 401-723-9595
Mailing address:
  • Phone: 401-725-2520
  • Fax: 401-723-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCPD00770
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: