=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760974646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE CICCONE LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2018
-----------------------------------------------------
Last Update Date | 05/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 CARNEGIE CTR STE 120
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-6235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-456-1576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6564
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08648-0564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 37PC00587900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------