Provider Demographics
NPI:1467504969
Name:LICHTY, DENISE MORIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:MORIN
Last Name:LICHTY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1032
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:628 2ND AVE STE 206
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:CA
Practice Address - Zip Code:94525-1175
Practice Address - Country:US
Practice Address - Phone:707-561-2805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20525103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA586396Medicaid