Provider Demographics
NPI:1134280092
Name:CICCHETTO, THERESA LOUISE (MFT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LOUISE
Last Name:CICCHETTO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 OLIVER RD
Mailing Address - Street 2:SUITE 193
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534
Mailing Address - Country:US
Mailing Address - Phone:707-514-5812
Mailing Address - Fax:707-474-9531
Practice Address - Street 1:1300 OLIVER RD
Practice Address - Street 2:SUITE 193
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-3413
Practice Address - Country:US
Practice Address - Phone:707-514-5812
Practice Address - Fax:707-422-3302
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43693106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist