Provider Demographics
NPI:1548683063
Name:DICICCO, JOANNA (RD, CDE)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:DICICCO
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:
Other - Last Name:SHEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:912 S OLD WOODWARD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6721
Mailing Address - Country:US
Mailing Address - Phone:248-631-4756
Mailing Address - Fax:
Practice Address - Street 1:912 S OLD WOODWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6721
Practice Address - Country:US
Practice Address - Phone:248-631-4756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
MI86008107133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered