Provider Demographics
NPI:1124240007
Name:VICIOSO, MYRIAM
Entity type:Individual
Prefix:MRS
First Name:MYRIAM
Middle Name:
Last Name:VICIOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-6704
Mailing Address - Country:US
Mailing Address - Phone:352-793-8661
Mailing Address - Fax:
Practice Address - Street 1:124 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-6704
Practice Address - Country:US
Practice Address - Phone:352-793-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887300300Medicaid
FLDJ470ZMedicare Oscar/Certification