Provider Demographics
NPI:1083732200
Name:ICKOWITZ, ALAN Y (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:Y
Last Name:ICKOWITZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DOUGLAS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-7953
Mailing Address - Country:US
Mailing Address - Phone:813-814-9839
Mailing Address - Fax:813-200-1044
Practice Address - Street 1:201 DOUGLAS AVE STE A
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-7953
Practice Address - Country:US
Practice Address - Phone:813-814-9839
Practice Address - Fax:813-200-1044
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5649103T00000X, 103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0163ZMedicare ID - Type Unspecified