Provider Demographics
NPI:1508934928
Name:REYNOLDS, TINA DICICCO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:DICICCO
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 NW 14TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-2505
Mailing Address - Country:US
Mailing Address - Phone:954-249-1871
Mailing Address - Fax:954-787-8116
Practice Address - Street 1:11401 NW 14TH CT
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-787-9711
Practice Address - Fax:954-787-8116
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7384103TB0200X, 103TC2200X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily