MEDICARE: DR. EVELYN MICCIO PSY.D.

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	103G00000X	Clinical Neuropsychologist	PSY18955	CA

General Provider Information

NPI Number	:	1538220397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVELYN MICCIO PSY.D.

Provider Business Mailing Address
First Line	:	4141 GEARY BLVD FL 3
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94118-3111
Country	:	US
Telephone Number	:	510-798-3311
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 GEARY BLVD FL 3
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94118-3111
Country	:	US
Telephone Number	:	510-798-3311
Fax Number	:

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	01/03/2022

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