Provider Demographics
NPI:1730317181
Name:LICATOVICH, JANE (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:LICATOVICH
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E 1ST ST FL 3E
Mailing Address - Street 2:
Mailing Address - City:BIRDSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19508-2375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 PHILADELPHIA AVE
Practice Address - Street 2:
Practice Address - City:SHILLINGTON
Practice Address - State:PA
Practice Address - Zip Code:19607-2764
Practice Address - Country:US
Practice Address - Phone:610-796-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005351L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist