Provider Demographics
NPI:1154163368
Name:LISBOA DE MELO, CICERA
Entity type:Individual
Prefix:
First Name:CICERA
Middle Name:
Last Name:LISBOA DE MELO
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 1:708 MARIGOLD AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2411
Mailing Address - Country:US
Mailing Address - Phone:978-401-8494
Mailing Address - Fax:
Practice Address - Street 1:708 MARIGOLD AVE
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2411
Practice Address - Country:US
Practice Address - Phone:978-401-8494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2716224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant