Provider Demographics
NPI:1598871865
Name:CICCIARELLI, THOMAS W (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:CICCIARELLI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PARNASSUS AVE
Mailing Address - Street 2:STE 601
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3608
Mailing Address - Country:US
Mailing Address - Phone:415-767-5199
Mailing Address - Fax:
Practice Address - Street 1:350 PARNASSUS AVE
Practice Address - Street 2:STE 601
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-3608
Practice Address - Country:US
Practice Address - Phone:415-767-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17298103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL172981Medicare ID - Type Unspecified