Provider Demographics
NPI:1720770290
Name:DICICCO, LAURA CARMELA (MA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CARMELA
Last Name:DICICCO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 ROLLSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1308
Mailing Address - Country:US
Mailing Address - Phone:516-532-4014
Mailing Address - Fax:
Practice Address - Street 1:149 ROLLSTONE AVE
Practice Address - Street 2:
Practice Address - City:WEST SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11796-1308
Practice Address - Country:US
Practice Address - Phone:516-532-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY$$$$$$$$$174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist