Provider Demographics
NPI:1437618097
Name:LICORISH, RENEE (DNP, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:
Last Name:LICORISH
Suffix:
Gender:F
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12702 TOEPPERWEIN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3267
Mailing Address - Country:US
Mailing Address - Phone:210-475-3617
Mailing Address - Fax:855-631-4341
Practice Address - Street 1:12702 TOEPPERWEIN RD STE 201
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3267
Practice Address - Country:US
Practice Address - Phone:210-475-3617
Practice Address - Fax:855-631-4341
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140787363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health