Healthcare Provider Details

I. General information

NPI: 1528370145
Provider Name (Legal Business Name): LISA ANN CICCONE BSW, BS, BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 PAVILION AVE
PROVIDENCE RI
02905-1522
US

IV. Provider business mailing address

66 PAVILION AVE
PROVIDENCE RI
02905-1522
US

V. Phone/Fax

Practice location:
  • Phone: 401-461-9110
  • Fax: 401-461-9194
Mailing address:
  • Phone: 401-461-9110
  • Fax: 401-461-9194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: