Provider Demographics
NPI:1417012113
Name:CICCONE, MARHENRA J (MS, CRC)
Entity Type:Individual
Prefix:MS
First Name:MARHENRA
Middle Name:J
Last Name:CICCONE
Suffix:
Gender:F
Credentials:MS, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8748 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-9690
Mailing Address - Country:US
Mailing Address - Phone:315-699-2925
Mailing Address - Fax:315-699-2925
Practice Address - Street 1:8748 WEAVER RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-9690
Practice Address - Country:US
Practice Address - Phone:315-699-2925
Practice Address - Fax:315-699-2925
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002935101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01978445Medicaid