Provider Demographics
NPI:1184022436
Name:LICASTRO, EMILY (LMP)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:
Last Name:LICASTRO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1502
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-1502
Mailing Address - Country:US
Mailing Address - Phone:360-321-5171
Mailing Address - Fax:
Practice Address - Street 1:5603 BAYVIEW RD # 13
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9735
Practice Address - Country:US
Practice Address - Phone:360-321-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60437283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist