Provider Demographics
NPI:1336266709
Name:DIMACALI, THEA MARIE GARCIA
Entity Type:Individual
Prefix:
First Name:THEA MARIE
Middle Name:GARCIA
Last Name:DIMACALI
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 1:500 SHADOW LAKES BLVD APT 28
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5023
Mailing Address - Country:US
Mailing Address - Phone:386-383-2024
Mailing Address - Fax:
Practice Address - Street 1:350 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7028
Practice Address - Country:US
Practice Address - Phone:386-677-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12530225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist