Provider Demographics
NPI:1669988838
Name:CHICA, CARLOS MANUEL
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:CHICA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SW 31ST ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-4555
Mailing Address - Country:US
Mailing Address - Phone:305-917-5901
Mailing Address - Fax:
Practice Address - Street 1:6844 INTERNATIONAL CENTER BLVD STE 500
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7159
Practice Address - Country:US
Practice Address - Phone:417-860-7640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-23
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician