Basic Information
| Provider Information | |||||||||
| NPI: | 1790884807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIROCCO | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 528 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436008 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHIEF EDDIE HOFFMAN HWY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1068 | AK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 020968600 | 05 | AK | MEDICAID | 800001335 | 01 | AK | MEDICARE ID -TYPE UNSPECIFIED | OTHER |