Provider Demographics
NPI:1225818727
Name:DIMICELLI, AUDREY ROSE
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:ROSE
Last Name:DIMICELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AUDREY
Other - Middle Name:ROSE
Other - Last Name:DIMICELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:475 OXFORD DR STE 104
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-7421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 OXFORD DR STE 104
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-7421
Practice Address - Country:US
Practice Address - Phone:855-782-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-23-289198106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician