Healthcare Provider Details

I. General information

NPI: 1336421718
Provider Name (Legal Business Name): TINA DICICCO REYNOLDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 05/06/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 NW 14TH CT
PEMBROKE PINES FL
33026
US

IV. Provider business mailing address

11401 NW 14TH CT
PEMBROKE PINES FL
33026-2505
US

V. Phone/Fax

Practice location:
  • Phone: 954-787-9711
  • Fax: 954-787-8116
Mailing address:
  • Phone: 954-249-1871
  • Fax: 954-787-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 7384
License Number StateFL

VIII. Authorized Official

Name: TINA DICICCO REYNOLDS
Title or Position: PSYCHOLOGIST/OWNER
Credential: PSY.D.
Phone: 954-787-9711