Provider Demographics
NPI:1992929491
Name:CICCARELLO, ROSEMARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:ROSEMARIE
Middle Name:
Last Name:CICCARELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PLYMOUTH ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2677
Mailing Address - Country:US
Mailing Address - Phone:973-744-1600
Mailing Address - Fax:973-744-3305
Practice Address - Street 1:33 PLYMOUTH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2677
Practice Address - Country:US
Practice Address - Phone:973-744-1600
Practice Address - Fax:973-744-3305
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3845103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
753174764OtherFEDERAL TAX ID