Provider Demographics
NPI:1407421001
Name:ZICCARDI, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:ZICCARDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 AVENIDA VAQUERO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2901
Mailing Address - Country:US
Mailing Address - Phone:520-686-1857
Mailing Address - Fax:
Practice Address - Street 1:621 AVENIDA VAQUERO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2901
Practice Address - Country:US
Practice Address - Phone:520-686-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC9666101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional