Provider Demographics
NPI:1912673831
Name:CICERO, DOUGLAS
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:CICERO
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 1:19 BANTA RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 POMPTON AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2946
Practice Address - Country:US
Practice Address - Phone:973-239-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst