Provider Demographics
NPI:1861120297
Name:DI VICO, MICAELA ANDREA
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:ANDREA
Last Name:DI VICO
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 1:3216 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7230
Mailing Address - Country:US
Mailing Address - Phone:786-426-9233
Mailing Address - Fax:
Practice Address - Street 1:12030 SW 129TH CT STE 209
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4584
Practice Address - Country:US
Practice Address - Phone:786-429-3619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA21667235Z00000X
FL10816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist