Provider Demographics
NPI:1740840669
Name:CICERO, CARRIE RENEE (MSED, BCBA, LABA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:RENEE
Last Name:CICERO
Suffix:
Gender:F
Credentials:MSED, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 ATWOODVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1106
Mailing Address - Country:US
Mailing Address - Phone:860-212-2077
Mailing Address - Fax:
Practice Address - Street 1:232 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1803
Practice Address - Country:US
Practice Address - Phone:413-525-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2684103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst