Provider Demographics
NPI:1407501901
Name:LICUIME, KARINA
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:LICUIME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5970 RANCHO MISSION RD
Mailing Address - Street 2:APT 247
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-430-9922
Mailing Address - Fax:
Practice Address - Street 1:11650 IBERIA PLACE SUITE 130, SAN DIEGO, CA 92128
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128
Practice Address - Country:US
Practice Address - Phone:858-264-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst