Provider Demographics
NPI:1013251180
Name:DIVICO, ALICIA ANNE (LMHC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANNE
Last Name:DIVICO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 N HIMES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7074
Mailing Address - Country:US
Mailing Address - Phone:813-546-0585
Mailing Address - Fax:813-449-4421
Practice Address - Street 1:550 N REO ST STE 240
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1062
Practice Address - Country:US
Practice Address - Phone:813-435-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007383800Medicaid