Provider Demographics
NPI:1265636302
Name:CICILEO, JULIE M (LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:CICILEO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:4760 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6063
Practice Address - Country:US
Practice Address - Phone:323-783-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS142491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical