Provider Demographics
NPI:1508116328
Name:ZEILICOVICH, DANIEL J
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:J
Last Name:ZEILICOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 JONES DR
Mailing Address - Street 2:APT 249
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-3580
Mailing Address - Country:US
Mailing Address - Phone:817-454-5579
Mailing Address - Fax:
Practice Address - Street 1:4225 OFFICE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3628
Practice Address - Country:US
Practice Address - Phone:817-454-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080579802Medicaid