Provider Demographics
NPI:1972272391
Name:CICCOLO, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CICCOLO
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 1:532 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-6003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:532 PAGE ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-6003
Practice Address - Country:US
Practice Address - Phone:508-960-1263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty