Provider Demographics
NPI:1710384318
Name:LICUANAN, LOURDES (SLP)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:LICUANAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 Q ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-4373
Mailing Address - Country:US
Mailing Address - Phone:864-230-0468
Mailing Address - Fax:
Practice Address - Street 1:5606 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-3571
Practice Address - Country:US
Practice Address - Phone:301-493-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT010000606225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist