Provider Demographics
NPI:1285911206
Name:COLACICCO, KEVIN (LMSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:COLACICCO
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 MARY ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2419
Mailing Address - Country:US
Mailing Address - Phone:315-272-2700
Mailing Address - Fax:
Practice Address - Street 1:628 MARY ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2419
Practice Address - Country:US
Practice Address - Phone:315-272-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720835251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical