Provider Demographics
NPI:1093097826
Name:LINCICUM, KATHERINE (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:LINCICUM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11303 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6003
Mailing Address - Country:US
Mailing Address - Phone:310-482-3260
Mailing Address - Fax:
Practice Address - Street 1:6957 CALIFORNIA AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1953
Practice Address - Country:US
Practice Address - Phone:206-938-5947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-389-3470Medicaid
CA953893470Medicaid
CA95-389-3470Medicare PIN
CA953893470Medicaid