Provider Demographics
NPI:1447061940
Name:CICERO, KRISTAN (LPC)
Entity type:Individual
Prefix:
First Name:KRISTAN
Middle Name:
Last Name:CICERO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 ROLESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6961
Mailing Address - Country:US
Mailing Address - Phone:570-881-4373
Mailing Address - Fax:
Practice Address - Street 1:601 CONESTOGA RD
Practice Address - Street 2:
Practice Address - City:VILLANOVA
Practice Address - State:PA
Practice Address - Zip Code:19085-1302
Practice Address - Country:US
Practice Address - Phone:570-881-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000918101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional