Provider Demographics
NPI:1033686514
Name:LICESE, ALLYSON LEIGH
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:LEIGH
Last Name:LICESE
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 1:21 MEEKER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2234
Mailing Address - Country:US
Mailing Address - Phone:203-206-3538
Mailing Address - Fax:
Practice Address - Street 1:28 RUSSETT LN
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-5803
Practice Address - Country:US
Practice Address - Phone:203-206-3538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT4557101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health