=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003200775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA JEAN DIGIULIO MA, MSED, LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2015
-----------------------------------------------------
Last Update Date | 03/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9417 SAINT JOE CENTER RD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46835-9259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-255-5289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13720 PENDLETON MILLS CT
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46814-8998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-348-6394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 39003727A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------