Provider Demographics
NPI:1275978082
Name:DR LUCIA LICAVOLI PHD PC
Entity Type:Organization
Organization Name:DR LUCIA LICAVOLI PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICAVOLI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:630-330-4191
Mailing Address - Street 1:3S101 ROCKWELL ST UNIT 886
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-2992
Mailing Address - Country:US
Mailing Address - Phone:630-330-4191
Mailing Address - Fax:
Practice Address - Street 1:24W788 75TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565
Practice Address - Country:US
Practice Address - Phone:630-330-4191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004881103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty