Provider Demographics
NPI:1609606565
Name:CICCIARELLI, KARA SUE (PHD, NCSP, LCP)
Entity type:Individual
Prefix:DR
First Name:KARA
Middle Name:SUE
Last Name:CICCIARELLI
Suffix:
Gender:F
Credentials:PHD, NCSP, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 N WILLOW LAKE CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8227
Mailing Address - Country:US
Mailing Address - Phone:309-683-7272
Mailing Address - Fax:
Practice Address - Street 1:7317 N WILLOW LAKE CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8227
Practice Address - Country:US
Practice Address - Phone:309-683-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071011250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty