Provider Demographics
NPI:1407515026
Name:CICARELLI, LYDIA CATHERINE (CPC)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:CATHERINE
Last Name:CICARELLI
Suffix:
Gender:F
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-5141
Mailing Address - Country:US
Mailing Address - Phone:509-216-3057
Mailing Address - Fax:
Practice Address - Street 1:901 N MONROE ST STE 201
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2148
Practice Address - Country:US
Practice Address - Phone:509-608-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61227010175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG61227010Medicaid