Provider Demographics
NPI:1720862691
Name:PICON, MONICA (PTA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:PICON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:PICON
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:4009 WINDING VINE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-2201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1826 N CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5905
Practice Address - Country:US
Practice Address - Phone:813-876-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA32993208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation