Provider Demographics
NPI:1497368807
Name:SICAN, LIZETH GUADALUPE (AMFT136150)
Entity Type:Individual
Prefix:
First Name:LIZETH
Middle Name:GUADALUPE
Last Name:SICAN
Suffix:
Gender:F
Credentials:AMFT136150
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 5166
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-5166
Mailing Address - Country:US
Mailing Address - Phone:323-249-2970
Mailing Address - Fax:
Practice Address - Street 1:1411 W 190TH ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4324
Practice Address - Country:US
Practice Address - Phone:323-249-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT136150106H00000X
106S00000X, 390200000X
CA136150106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program