Provider Demographics
NPI:1003801457
Name:DICICCO, F VICTORIA (PHD)
Entity Type:Individual
Prefix:
First Name:F
Middle Name:VICTORIA
Last Name:DICICCO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 GOVERNOR DRIVE
Mailing Address - Street 2:STE 108
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122
Mailing Address - Country:US
Mailing Address - Phone:858-452-5800
Mailing Address - Fax:858-546-0411
Practice Address - Street 1:5190 GOVERNOR DR
Practice Address - Street 2:STE 108
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2847
Practice Address - Country:US
Practice Address - Phone:858-452-5800
Practice Address - Fax:858-546-0411
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7974103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY079740Medicaid
R62254Medicare UPIN
CACP7974Medicare PIN