Provider Demographics
NPI:1619463999
Name:HICIANO, CARLEN RAQUEL
Entity Type:Individual
Prefix:
First Name:CARLEN
Middle Name:RAQUEL
Last Name:HICIANO
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 1:102 W 183RD ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-1107
Mailing Address - Country:US
Mailing Address - Phone:646-407-5872
Mailing Address - Fax:
Practice Address - Street 1:45-10 94TH ST
Practice Address - Street 2:ROOM 116A
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-271-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244371Medicaid