Provider Demographics
NPI:1992446710
Name:DICOCCO, MARYELLEN
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:DICOCCO
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 1:32602 RUSTIC RISE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:FL
Mailing Address - Zip Code:33576-7450
Mailing Address - Country:US
Mailing Address - Phone:518-857-6929
Mailing Address - Fax:
Practice Address - Street 1:1933 STONEBRIAR DR APT 206
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-4929
Practice Address - Country:US
Practice Address - Phone:518-857-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool