Provider Demographics
NPI:1548073513
Name:WADSWORTH, VIVICA
Entity type:Individual
Prefix:
First Name:VIVICA
Middle Name:
Last Name:WADSWORTH
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 1:14230 LAZEE LN
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-7626
Mailing Address - Country:US
Mailing Address - Phone:352-668-8274
Mailing Address - Fax:
Practice Address - Street 1:14230 LAZEE LN
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-7626
Practice Address - Country:US
Practice Address - Phone:352-668-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health