Provider Demographics
NPI:1225767361
Name:LICCIARDI, ANGELICA J (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:J
Last Name:LICCIARDI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:ANGELICA
Other - Middle Name:J
Other - Last Name:HANDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:19 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2010
Mailing Address - Country:US
Mailing Address - Phone:631-294-3178
Mailing Address - Fax:
Practice Address - Street 1:3253 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1411
Practice Address - Country:US
Practice Address - Phone:631-730-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116074104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker