Provider Demographics
NPI:1821502220
Name:CICCARELLO, DANIEL (LSW)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:CICCARELLO
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 CARNEGIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2641
Mailing Address - Country:US
Mailing Address - Phone:216-318-7872
Mailing Address - Fax:
Practice Address - Street 1:3500 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2641
Practice Address - Country:US
Practice Address - Phone:216-318-7872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.1802501104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0346310Medicaid