Provider Demographics
NPI:1629452115
Name:LUCILLO, MALLORY SHEILA (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:SHEILA
Last Name:LUCILLO
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5860 GOLDEN GATE PKWY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-7459
Mailing Address - Country:US
Mailing Address - Phone:239-352-7600
Mailing Address - Fax:239-352-7609
Practice Address - Street 1:5860 GOLDEN GATE PKWY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7459
Practice Address - Country:US
Practice Address - Phone:239-352-7600
Practice Address - Fax:239-352-7609
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11518703103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst