Provider Demographics
NPI:1063490514
Name:AMICK, LETICIA C (PHD)
Entity Type:Individual
Prefix:DR
First Name:LETICIA
Middle Name:C
Last Name:AMICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LETICIA
Other - Middle Name:C
Other - Last Name:AMICK LOFTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:121 W LEXINGTON DR
Mailing Address - Street 2:SUITE 346
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2203
Mailing Address - Country:US
Mailing Address - Phone:818-480-6517
Mailing Address - Fax:
Practice Address - Street 1:121 W LEXINGTON DR
Practice Address - Street 2:SUITE 346
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2203
Practice Address - Country:US
Practice Address - Phone:818-480-6517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3497103TC2200X
CAPSY 21549103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGV818ZOtherMEDICARE PTAN
AZQ47602Medicare UPIN