Provider Demographics
NPI:1043583743
Name:CICERO, COLLEEN GRACE (LISW)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:GRACE
Last Name:CICERO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 GORDON RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1334
Mailing Address - Country:US
Mailing Address - Phone:440-227-9056
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-12
Last Update Date:2012-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.10003001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical