Provider Demographics
NPI:1407211162
Name:CICERO, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CICERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 CROOKED HILL RD
Mailing Address - Street 2:BLDG 47
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1019
Mailing Address - Country:US
Mailing Address - Phone:631-761-2139
Mailing Address - Fax:
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:BLDG 47
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-761-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1578627785175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist