Provider Demographics
NPI:1083925598
Name:CICERO, SCOTT DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DAVID
Last Name:CICERO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 OLD ORANGEBURG RD
Mailing Address - Street 2:BUILDING 35
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-1157
Mailing Address - Country:US
Mailing Address - Phone:845-398-2190
Mailing Address - Fax:845-398-6592
Practice Address - Street 1:2 FIRST AVE.
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962
Practice Address - Country:US
Practice Address - Phone:845-680-4024
Practice Address - Fax:845-680-8905
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011369103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent