Provider Demographics
NPI:1225759871
Name:BRIAN LICORISH PSYCHIATRY LLC
Entity Type:Organization
Organization Name:BRIAN LICORISH PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:KENRICK
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:LICORISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-244-0104
Mailing Address - Street 1:2108 N ST STE N
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2108 N ST STE N
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5712
Practice Address - Country:US
Practice Address - Phone:408-384-3758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)