Provider Demographics
NPI:1952171241
Name:LACIVITA, KIMBERLY (PSYD PA)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:LACIVITA
Suffix:
Gender:F
Credentials:PSYD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 SANDRALA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-3425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7345 INTERNATIONAL PL STE 109
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8468
Practice Address - Country:US
Practice Address - Phone:941-702-9978
Practice Address - Fax:941-203-4822
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1610103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool