Provider Demographics
NPI:1447748538
Name:LICANO, ROBERTO ALEJANDRO (CDCA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ALEJANDRO
Last Name:LICANO
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAY DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-2024
Mailing Address - Country:US
Mailing Address - Phone:513-367-4444
Mailing Address - Fax:513-367-4449
Practice Address - Street 1:120 MAY DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-2024
Practice Address - Country:US
Practice Address - Phone:513-367-4444
Practice Address - Fax:513-367-4449
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.171989101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0278938Medicaid