Provider Demographics
NPI:1104235191
Name:CICCARELLI, BREANNA (LMSW)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CICCARELLI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5467 UPPER MOUNTAIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-1854
Mailing Address - Country:US
Mailing Address - Phone:716-278-8176
Mailing Address - Fax:716-278-8130
Practice Address - Street 1:5467 UPPER MOUNTAIN RD STE 200
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-1854
Practice Address - Country:US
Practice Address - Phone:716-278-8176
Practice Address - Fax:716-278-8130
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084688-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker