Provider Demographics
NPI:1700076866
Name:DI VICO, KRISTIN ANN (LMSW, MSPT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:DI VICO
Suffix:
Gender:F
Credentials:LMSW, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 N SHELLEY ST
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1441
Mailing Address - Country:US
Mailing Address - Phone:914-588-6186
Mailing Address - Fax:
Practice Address - Street 1:275 NORTH ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-1140
Practice Address - Country:US
Practice Address - Phone:914-967-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPT-014318-12251P0200X
NY126167-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics