Provider Demographics
NPI:1720607195
Name:MUCCIOLO, CHRISITNA AMORET
Entity Type:Individual
Prefix:
First Name:CHRISITNA
Middle Name:AMORET
Last Name:MUCCIOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 NE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2317
Mailing Address - Country:US
Mailing Address - Phone:862-812-1077
Mailing Address - Fax:
Practice Address - Street 1:1112 NE 16TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2317
Practice Address - Country:US
Practice Address - Phone:862-812-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17306235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist