Basic Information
| Provider Information | |||||||||
| NPI: | 1669467015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICICCO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5190 GOVERNOR DR | ||||||||
| Address2: | STE 108 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921222847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585461211 | ||||||||
| FaxNumber: | 8585460411 | ||||||||
| Practice Location | |||||||||
| Address1: | 5190 GOVERNOR DR | ||||||||
| Address2: | STE 108 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921222847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585461211 | ||||||||
| FaxNumber: | 8585460411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY5667 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PSY056670 | 05 | CA | MEDICAID |