Provider Demographics
NPI:1831625466
Name:CICCHETTI, RICHARD J (LCPC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:CICCHETTI
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 N MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6309
Mailing Address - Country:US
Mailing Address - Phone:773-251-8714
Mailing Address - Fax:
Practice Address - Street 1:1142 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:773-251-8714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011229101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILILLINOISMedicaid