Healthcare Provider Details

I. General information

NPI: 1538683198
Provider Name (Legal Business Name): CATHLEEN LAUREL CIVIELLO PHD, ABPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 H. HWY 441 SUITE 404
LADY LAKE FL
32159
US

IV. Provider business mailing address

1200 STEUART ST UNIT 922
BALTIMORE MD
21230-5385
US

V. Phone/Fax

Practice location:
  • Phone: 352-291-2407
  • Fax: 352-416-1814
Mailing address:
  • Phone: 443-691-6641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2387
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY8698
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: