Provider Demographics
NPI:1417002585
Name:DINICOLAS, MARY LOU (LMT)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:DINICOLAS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 S PINE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2831
Mailing Address - Country:US
Mailing Address - Phone:954-593-9735
Mailing Address - Fax:954-689-3771
Practice Address - Street 1:4149 S PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2831
Practice Address - Country:US
Practice Address - Phone:954-593-9735
Practice Address - Fax:954-689-3771
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist