Healthcare Provider Details

I. General information

NPI: 1184877227
Provider Name (Legal Business Name): LICIA A DEVIVO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 N JEROME AVE
MARGATE CITY NJ
08402-1527
US

IV. Provider business mailing address

607 N JEROME AVE
MARGATE CITY NJ
08402-1527
US

V. Phone/Fax

Practice location:
  • Phone: 609-822-1108
  • Fax: 609-822-1106
Mailing address:
  • Phone: 609-822-1108
  • Fax: 609-822-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05372400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: