Provider Demographics
NPI:1023046133
Name:DEMICO, ALISA DANELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:DANELLE
Last Name:DEMICO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6179 ECLIPSE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-8434
Mailing Address - Country:US
Mailing Address - Phone:904-534-8111
Mailing Address - Fax:904-880-9007
Practice Address - Street 1:9803 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8854
Practice Address - Country:US
Practice Address - Phone:904-880-9001
Practice Address - Fax:904-880-9007
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884233700Medicaid