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General NPI Number Information
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NPI Number | 1548784762
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Entity Type | Individual
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Provider Name | LISA MARIE CICCONE LMSW
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Gender | Female
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Dates
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Enumeration Date | 07/30/2017
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Last Update Date | 07/30/2017
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Provider Practice Location Address
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Address Line | 319 BROADWAY
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City | PORT EWEN
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State | NY
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Zip | 12466-5501
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Country | US
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Telephone | 845-339-8707
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 193
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City | ESOPUS
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State | NY
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Zip | 12429-0193
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Country | US
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Telephone | 18455943162
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YS0200X
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Taxonomy Name | School Counselor
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License Number | 095647
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License Number State | NY
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