Provider Demographics
NPI:1508241779
Name:LICUANAN, BRIAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:LICUANAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HERRINGBONE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620
Mailing Address - Country:US
Mailing Address - Phone:714-469-1418
Mailing Address - Fax:
Practice Address - Street 1:17 HERRINGBONE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620
Practice Address - Country:US
Practice Address - Phone:714-469-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27276103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling