Provider Demographics
NPI:1902118847
Name:MICCICHE, MADELINE RISSA (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:RISSA
Last Name:MICCICHE
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ALLENS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3304
Mailing Address - Country:US
Mailing Address - Phone:585-746-2191
Mailing Address - Fax:
Practice Address - Street 1:110 ALLENS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3304
Practice Address - Country:US
Practice Address - Phone:585-746-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072098-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical