Provider Demographics
NPI:1477681302
Name:LICITRA, CAROL ANN (LMHC)
Entity Type:Individual
Prefix:
First Name:CAROL ANN
Middle Name:
Last Name:LICITRA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3234
Mailing Address - Country:US
Mailing Address - Phone:617-877-7481
Mailing Address - Fax:617-844-1606
Practice Address - Street 1:930 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3234
Practice Address - Country:US
Practice Address - Phone:617-877-7481
Practice Address - Fax:617-844-1606
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5361101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health