Provider Demographics
NPI:1881878304
Name:CICCARELLI, REBECCA C (MS CCC/SLP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:C
Last Name:CICCARELLI
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:C
Other - Last Name:LOUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5865 MILLWICK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-6733
Mailing Address - Country:US
Mailing Address - Phone:770-559-0129
Mailing Address - Fax:
Practice Address - Street 1:5865 MILLWICK DR
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-6733
Practice Address - Country:US
Practice Address - Phone:770-559-0129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5123-SL235Z00000X
GASLP008542235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist