=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972064939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CICCONE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2019
-----------------------------------------------------
Last Update Date | 03/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 BOARDMAN CANFIELD RD STE 1
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-720-6463
-----------------------------------------------------
Fax | 330-706-4006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 BOARDMAN CANFIELD RD STE 1
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-720-6463
-----------------------------------------------------
Fax | 330-706-4006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUDY CICCONE
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 330-720-6463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------