Provider Demographics
NPI:1538683198
Name:CIVIELLO, CATHLEEN LAUREL (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:CATHLEEN
Middle Name:LAUREL
Last Name:CIVIELLO
Suffix:
Gender:F
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 STEUART ST UNIT 922
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5385
Mailing Address - Country:US
Mailing Address - Phone:443-691-6641
Mailing Address - Fax:
Practice Address - Street 1:929 H. HWY 441
Practice Address - Street 2:SUITE 404
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-291-2407
Practice Address - Fax:352-416-1814
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2387103T00000X
FLPY8698103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist