Basic Information
| Provider Information | |||||||||
| NPI: | 1093963639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CICCONE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14600 SHERMAN WAY STE 100D | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914052283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183746901 | ||||||||
| FaxNumber: | 8183746908 | ||||||||
| Practice Location | |||||||||
| Address1: | 14600 SHERMAN WAY STE 100D | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914052283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183746901 | ||||||||
| FaxNumber: | 8183746908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 63736 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01536011 | 01 | CA | MEDI-CAL | OTHER |