Provider Demographics
NPI:1053148791
Name:CICCONE, MICHELLE I
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CICCONE
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4621
Mailing Address - Country:US
Mailing Address - Phone:347-424-5093
Mailing Address - Fax:
Practice Address - Street 1:1651 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5849
Practice Address - Country:US
Practice Address - Phone:718-998-1415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist