Healthcare Provider Details

I. General information

NPI: 1821195249
Provider Name (Legal Business Name): MARA E. CICALONI M.S., LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 MAIN ST.
CHESTER VT
05143
US

IV. Provider business mailing address

PO BOX 844
CHESTER VT
05143-0844
US

V. Phone/Fax

Practice location:
  • Phone: 802-875-5335
  • Fax: 802-875-5337
Mailing address:
  • Phone: 802-875-5335
  • Fax: 802-875-5337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000643
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: