=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972444263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLY MARIE RICCIO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2026
-----------------------------------------------------
Last Update Date | 04/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 BAYOU BLVD STE 30
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-420-9317
-----------------------------------------------------
Fax | 850-505-3078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 BAYOU BLVD STE 30
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-420-9317
-----------------------------------------------------
Fax | 850-505-3078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW26250
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------