Provider Demographics
NPI:1003119504
Name:LICINI, KERRI S (MA, MAED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KERRI
Middle Name:S
Last Name:LICINI
Suffix:
Gender:F
Credentials:MA, MAED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WELLS RD # 15-16
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2337
Mailing Address - Country:US
Mailing Address - Phone:904-637-1400
Mailing Address - Fax:904-637-1400
Practice Address - Street 1:1700 WELLS RD # 15-16
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2337
Practice Address - Country:US
Practice Address - Phone:904-637-1400
Practice Address - Fax:904-637-1400
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-13-14323Other1-13-14323