Provider Demographics
NPI:1548784762
Name:CICCONE, LISA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CICCONE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:ESOPUS
Mailing Address - State:NY
Mailing Address - Zip Code:12429-0193
Mailing Address - Country:US
Mailing Address - Phone:1845-594-3162
Mailing Address - Fax:
Practice Address - Street 1:319 BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT EWEN
Practice Address - State:NY
Practice Address - Zip Code:12466-5501
Practice Address - Country:US
Practice Address - Phone:845-339-8707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-30
Last Update Date:2017-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095647101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool