Provider Demographics
NPI:1114544319
Name:FELICO, REBECCA ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:FELICO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 12TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6379
Mailing Address - Country:US
Mailing Address - Phone:804-683-7060
Mailing Address - Fax:
Practice Address - Street 1:11555 CENTRAL PKWY STE 701
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2699
Practice Address - Country:US
Practice Address - Phone:904-209-9534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW168261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1902239270OtherTRACY RILEY COUNSELING