=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588973119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA A RICCIO PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2010
-----------------------------------------------------
Last Update Date | 10/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1318 MEMORIAL DRIVE BRAZOS VALLEY REHABILITATION CENTER
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-862-4906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | DEPARTMENT OF EDUCATIONAL PSYCHOLOGY TAMU 4225
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77843-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-862-4906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 31026
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 30663
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------