MEDICARE: ALISA DANELLE DEMICO M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA4664	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023046133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISA DANELLE DEMICO M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	6179 ECLIPSE CIR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-8434
Country	:	US
Telephone Number	:	904-534-8111
Fax Number	:	904-880-9007

Provider Business Practice Location Address
First Line	:	9803 OLD SAINT AUGUSTINE RD
Second Line	:	SUITE 7
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-8854
Country	:	US
Telephone Number	:	904-880-9001
Fax Number	:	904-880-9007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	12/19/2012

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Directions to “ ALISA DANELLE DEMICO M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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