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General NPI Number Information
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NPI Number | 1538683198
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Entity Type | Individual
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Provider Name | CATHLEEN LAUREL CIVIELLO PHD, ABPP
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Gender | Female
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Dates
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Enumeration Date | 07/26/2017
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Last Update Date | 07/26/2017
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Provider Practice Location Address
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Address Line | 929 H. HWY 441 SUITE 404
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City | LADY LAKE
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State | FL
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Zip | 32159
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Country | US
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Telephone | 352-291-2407
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Fax | 352-416-1814
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Provider Business Mailing Address
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Address Line | 1200 STEUART ST UNIT 922
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City | BALTIMORE
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State | MD
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Zip | 21230-5385
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Country | US
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Telephone | 443-691-6641
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2387
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY8698
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License Number State | FL
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