Provider Demographics
NPI:1760566046
Name:CICHANOWICZ, CHUCK (LMHC,MS,MDIV,IMAC,)
Entity Type:Individual
Prefix:
First Name:CHUCK
Middle Name:
Last Name:CICHANOWICZ
Suffix:
Gender:M
Credentials:LMHC,MS,MDIV,IMAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CANDLELIGHT PLZ
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE BRA
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5628
Mailing Address - Country:US
Mailing Address - Phone:765-449-9117
Mailing Address - Fax:
Practice Address - Street 1:3768 ROME DRIVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-449-9115
Practice Address - Fax:765-446-4224
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000389A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health