Provider Demographics
NPI:1679091326
Name:CICCHINELLI, SARA R (LPCC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:R
Last Name:CICCHINELLI
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7389 N CHESTNUT COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3540
Mailing Address - Country:US
Mailing Address - Phone:330-760-1666
Mailing Address - Fax:
Practice Address - Street 1:7519 MENTOR AVE STE 211
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5434
Practice Address - Country:US
Practice Address - Phone:440-701-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1400204251S00000X
OHE.1901289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2844093Medicaid