Provider Demographics
NPI:1164827838
Name:PERSONAL WELLNESS SOLUTIONS, P.A.
Entity Type:Organization
Organization Name:PERSONAL WELLNESS SOLUTIONS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DIVICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-384-4215
Mailing Address - Street 1:13801 N DALE MABRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2412
Mailing Address - Country:US
Mailing Address - Phone:813-390-1425
Mailing Address - Fax:
Practice Address - Street 1:13801 N DALE MABRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2412
Practice Address - Country:US
Practice Address - Phone:813-390-1425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11494101YM0800X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty