Provider Demographics
NPI:1518032051
Name:CIOCCA, JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CIOCCA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:TN
Mailing Address - Zip Code:38029-0269
Mailing Address - Country:US
Mailing Address - Phone:901-371-0019
Mailing Address - Fax:901-373-9613
Practice Address - Street 1:2014 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3945
Practice Address - Country:US
Practice Address - Phone:901-371-0018
Practice Address - Fax:901-373-9613
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP000903103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2006267OtherBCBS
TN3682159Medicare ID - Type UnspecifiedMEDICARE