Provider Demographics
NPI:1619398567
Name:LICH, BRYAN V (CCP)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:V
Last Name:LICH
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17080 SAFETY ST STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7506
Mailing Address - Country:US
Mailing Address - Phone:888-499-5672
Mailing Address - Fax:888-501-0844
Practice Address - Street 1:17080 SAFETY ST STE 109
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-7506
Practice Address - Country:US
Practice Address - Phone:888-499-5672
Practice Address - Fax:888-501-0844
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA169282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital