Provider Demographics
NPI:1518332600
Name:LICARI, ANDREA (MA NCC LAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LICARI
Suffix:
Gender:F
Credentials:MA NCC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 88 W
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-2320
Mailing Address - Country:US
Mailing Address - Phone:732-785-1900
Mailing Address - Fax:
Practice Address - Street 1:1500 ROUTE 88 W
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2320
Practice Address - Country:US
Practice Address - Phone:732-785-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00253600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid