Provider Demographics
NPI:1912234873
Name:CICCO, STEPHEN A
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:A
Last Name:CICCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-1736
Mailing Address - Country:US
Mailing Address - Phone:978-740-9776
Mailing Address - Fax:
Practice Address - Street 1:16 CLARK ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-1736
Practice Address - Country:US
Practice Address - Phone:978-740-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator