Provider Demographics
NPI:1003117268
Name:LICOAN, SUSAN J (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:LICOAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1578
Mailing Address - Street 2:
Mailing Address - City:HONOKAA
Mailing Address - State:HI
Mailing Address - Zip Code:96727-1578
Mailing Address - Country:US
Mailing Address - Phone:808-896-7186
Mailing Address - Fax:808-962-6943
Practice Address - Street 1:39 3301 MILO PLACE
Practice Address - Street 2:
Practice Address - City:OOKALA
Practice Address - State:HI
Practice Address - Zip Code:96774
Practice Address - Country:US
Practice Address - Phone:808-896-7186
Practice Address - Fax:808-962-6943
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2013-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1214103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical