Provider Demographics
NPI:1215123260
Name:IDAROLA, LUCILLE (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LUCILLE
Middle Name:
Last Name:IDAROLA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 SW CENTERVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-6110
Mailing Address - Country:US
Mailing Address - Phone:352-339-5753
Mailing Address - Fax:
Practice Address - Street 1:2495 SW CENTERVILLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-6110
Practice Address - Country:US
Practice Address - Phone:352-339-5753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-23
Last Update Date:2007-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6006235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist